key: cord-0054907-7b3oewbj
authors: nan
title: Irish Thoracic Society Annual Scientific Meeting 2020
date: 2021-01-07
journal: Ir J Med Sci
DOI: 10.1007/s11845-020-02450-w
sha: 6fdae59bef6bdfa403a9fce1678aa8f8480d90a0
doc_id: 54907
cord_uid: 7b3oewbj

nan

1 Edwards C, 1 Costello E, 2 Curley M, 2 Smyth L, 3 O'Seaghdha C, 3 Costello R, 4 O'Reilly KMA. 1 patientMpower Ltd., 21 Denzille Lane, Saint Peters, Dublin D02 EY19. 2 HSE Digital Transformation, Dr. Steevens' Hospital, Dublin D08 W2A8. 3 Beaumont Hospital, Beaumont Road, Dublin D09 V2N0. 4 Mater Misericordiae University Hospital, Eccles Street, Dublin D07 R2WY.

Ireland experienced a wave of Covid-19 (SARS-CoV-2) infection starting in February 2020 with 25,462 cases (527/100,000) by 30 June 2020. An important strategy to free up in-hospital capacity was development of capability to remotely manage Covid-19 in lower-risk patients with mild/moderate symptoms. patientMpower approached the HSE Digital Transformation team and external medical advisers with a design concept for a remote monitoring platform for Covid-19. This consists of a patient-facing app + pulse oximeter (Bluetooth-connected Nonin 3230) enabling patients to record symptoms (e.g. dyspnoea, diarrhoea) & oxygen saturation (SpO2). Patient-recorded data was viewed in real time by their healthcare centre via dedicated monitoring portal. Criteria for remote monitoring included: Covid-19 symptoms, positive for SARS-CoV-2, young age, absence of serious concomitant conditions, need for continued observation post-discharge. Treatment centres emailed app installation instructions to their patients. Between 13 March and 30 June 2020, 874 patients at 8 primary & 15 secondary care centres had been monitored remotely (median duration: 13 days). 778 patients (89%) gave consent to use of their pseudonymised data for research. Summary statistics from this cohort shown in Table. Remote monitoring of Covid-19 in appropriate patients can free up inhospital capacity and provide data to support research. Ground glass opacification (GGO) is a radiological sign associated with various lung pathologies, which has recently been described in SARS-CoV-2 respiratory infection 1 .

We studied the incidence of new GGO on CT-Thorax during a period of the SARS-CoV-2 pandemic in OLOL Hospital between 29 February and 31 July 2020 and examined interval radiology.

During the study period, 64 GGOs were reported on CT-Thorax, compared to 29 in the previous year (increase of 121%, p <0.01). SARS-CoV-2 PCR was detected in 33 cases (51.6%), while 20 cases were highly suspicious for SARS-CoV-2 despite undetectable PCR (31.3%).

Remaining cases of GGO included decompensated heart failure (ADHF; 3), pneumocystis pneumonia (PCP; 2), amiodarone-induced pneumonitis (1) and acute interstitial pneumonitis (AIP; 1).

Although PCR testing is the gold standard in diagnosis of SARS-CoV-2 respiratory infection, CT-thorax findings including GGO are sensitive and are often seen before PCR detection 1 . Our data shows that the incidence of GGO increased by 3-fold during the pandemic, suggesting that GGO is more sensitive than PCR testing but that other acute respiratory pathologies should be considered.

Evidence suggests that the use of continuous positive airway pressure (CPAP) in Covid-19 pneumonitis can avoid intubation in some patients. High flow nasal oxygen (HFNO) use has been contentious. We retrospectively reviewed the clinical notes for all respiratory patients admitted between March 1 st and May 31 st 2020 to identify patients with a diagnosis of COVID-19 pneumonitis requiring respiratory support and recorded patient demographics and outcomes. 56 patients who received respiratory support were identified. The median age (IQR) was 65 (54,77 years), 65% were male, and overall mortality was 44%. 3 (5%) patients were intubated without trial of non-invasive ventilation (NIV) and 1 patient received BiPAP (Bilevel positive airway pressure) due to underlying COPD. The In conclusion, the mortality in patients with COVID-19 pneumonia who required respiratory support was high, and over half of the patients for full escalation in the event of treatment failure required invasive ventilation. Further studies are clearly required, comparing patient comorbidities and outcomes using different modalities of respiratory support.

Persistent breathlessness following COVID-19 infection is becoming an increasingly observed phenomenon. A recent Italian study noted than over 40% of patients hospitalised with COVID-19 infection had persistent dyspnoea at 60 days after the onset of COVID-19 infection 1 . We have recently started receiving referrals for such patients. Here we present their Pulmonary Function Data performed at UHL. 7 Patients, (2M/ 5F) aged 34-66, with a Positive Nasal Swab/Throat Swab for COVID -19 between January 2020 and March 2020 were referred for Pulmonary Function due to persistence shortness of breath. Spirometry and DLCO were performed 45-60 days post Covid-19 infection with confirmed negative swab. 6 patients had normal FEV1, FVC and FEV1/FVC ratio. 1 patient had normal FVC and FEV1/FVC% with a mildly reduced FEV1 (ATS 2005) . The same patient with low FEV1 has also low transfer factor; the other 6 patients had normal transfer factor. Most of these patients were very active prior to COVID-19 infection. While most of these patients have normal lung function, there is a significant reduction in their normal activity level due to persistent shortness of breath. In this study, the persistent shortness of breath in this patient group does not suggest an association with impaired lung function. Further longitudinal lung function measurements in a larger group of symptomatic patients post COVID-19 infection are necessary, as well as further studies to help elucidate the pathophysiology of persistent symptoms despite normal baseline lung function testing. Coronavirus disease 19 (COVID-19), caused by SARS-CoV-2, is an acute viral respiratory disease. Characteristic symptoms include fever, cough, fatigue and dyspnoea 1 . Exercise is an integral component of physiotherapy in the management of respiratory disorders, with greater benefits for community acquired pneumonia than respiratory physiotherapy alone 2 . There is limited data on the effects of exercise rehabilitation in COVID-19. This audit aims to analyse the outcome of inpatient exercise rehabilitation on functional outcomes in patients with COVID-19. A prospective audit was completed, with data collected and analysed using an excel spreadsheet Five patients aged 78±4 received physiotherapy intervention, including exercise rehabilitation, with outcome measures completed at initial assessment and at one week. The primary outcome measure was the two minute walk test (2MWT) to measure functional capacity. The secondary outcomes were muscle strength measured through five times sit-to-stand, and dyspnoea measured by the medical research council (MRC) dyspnoea scale. Functional outcomes improved in all patients. There was an overall 37% improvement in 2MWT distance, 29% improvement in muscle strength and 47% improvement in dyspnoea.

In conclusion, as has been shown in other respiratory disorders 2 , one week of inpatient exercise rehabilitation improved functional capacity, muscle strength and dyspnoea in older people with COVID-19. 1 Naas General Hospital (NGH) is a model 3 public acute hospital. Kildare to date has the highest incidence rate of COVID-19 outside of the capital Dublin.

Retrospective, single-centre case series of 106 consecutive hospitalised patients with confirmed COVID-19 admitted to NGH between March 8 th and May 28 th . Demographics, clinical, labarotory, radiological, and treatment data were collected, analysed and compared between survivors and non survivors. Of 106 patients, the median age was 72 years and 58% were men. The majority of the cases were community acquired (50%). Common symptoms included cough (70%), fever (64%) and Dyspnoea (65%). 70% had infiltrates on CXR. Majority of the patients (83%) received antibacterial therapy, 18% received steroids and five received tocilizumab. Twelve patients were transferred to ICU, of whom 9 received invasive ventilation. ICU mortality rate was 33%. Non survivors were older (median age 79 years vs 65 years), had higher Charlson comorbidity index (median 5.4 vs 3.7), were more lymphopenic with higher DDimers and CRP values. Overall mortality rate in NGH was 30%. We found that older age, underlying comorbidities, lymphopenia and high levels of CRP and DDimers were risk factors for death of COVID-19 patients which can be helpful to identify patients at higher risk at an early stage. An accurate, predictive clinical risk score could allow early identification and better treatment of deteriorating COVID-19 patients and estimate future healthcare resource demand. A 13-point multivariable, clinical early warning index, the COVID Critical Care Index (CCCI) was developed through consensus of a panel of experts, implemented in a digital clinical support tool, and validated in a cohort of 256 patients with COVID-19. Increase in CCCI was strongly predictive of eventual ICU transfer or death, best predicted by a score of ≥6 at any point during admission (HR=5.6 (3.38 to 9.28)). CCCI was a stronger predictor of death/ICU admission than NEWS score or Ratio of Oxygen Saturation (ROX) index (area under the ROC curve (AUROC) of 0·93 (0·89 to 0·96) for CCCI compared to 0·87 (0·82 to 0·92) for NEWS and 0·79 (0·71 to 0·86) for ROX). CCCI is predictive of death/ICU admission at both ≥6 and ≥24 hours prior (AUROC = 0.9 (0.86 to 0.95) and 0·87 (0·82 to 0·92), respectively). CCCI predicts which COVID-19 patients are high risk with greater accuracy than established clinical deterioration scores, providing a useful time window to estimate future ICU bed demand, facilitate earlier and more effective treatment, and allow better resource allocation. Our Lady's of Lourdes Hospital, Drogheda, Co Louth.

One of the most important clinical debate for the treatment in of Covid-19 acute respiratory failure includes the role of noninvasive ventilation (NIV) such as continuous positive pressure (CPAP) and the threshold for mechanical ventilation (IMV) (1) . 129 laboratory-confirmed Covid-19 patients in Our Lady of Lourdes Hospital were admitted. Twenty-seven patients with acute hypoxic respiratory failure that were not reaching target SaO2 and pO2 received CPAP during inpatient hospital stay with age (mean ± SD) of 59 ± 13. Fourteen patients (37%) received at last three session of conscious prone position. Ten subjects subsequently were intubated and ventilated with two deaths. No death was observed in subjects receiving CPAP alone with a 100% success rate. PFR before CPAP initiation was negatively correlated with the maximum pressure to achieve target saturations (rs=-0.61,p=0.009)). PFR at 24 hours after commencement of CPAP was significantly higher (mean± SD) (207±92) compared to before CPAP initiation (p=0.03). The average day for CPAP treatment was (mean± SD) 4.6±4.2 days.

In conclusion, this study urgently and importantly shows that CPAP is a useful first-line treatment for Covid-19 acute respiratory failure in a non-ICU setting. PFR is useful to determine response of CPAP which may avoid mechanical ventilation.

SARS-CoV-2/COVID-19 is now recognised as a significant risk factor for the development of venous thromboembolism (VTE) in hospitalised patients 1 . Correct thromboprophylaxis is vital to decrease associated morbidity and mortality. Our aim was to improve the rate of appropriate VTE prophylaxis in patients admitted to Beaumont hospital with COVID-19. An audit of initial practice found significant room for improvement in VTE prophylaxis prescription. We assessed this over two time periods to determine if practice improved without intervention. We performed three cycles of audit/QI to improve practice locally. At baseline, 53% of patients received appropriate VTE prophylaxis. As data emerged that COVID-19 was associated with significant VTE disease, this improved to 58%. An education intervention, a cartoon promoting VTE prophylaxis circulated locally and on social media, and involvement of a CNM-champion to improve weight measurement were chosen as interventions and tested. Weight appropriate VTE prophylaxis improved to 100% following our interventions. Appropriate prophylactic/therapeutic anticoagulation prescription In conclusion, our QI project improved local prescription of VTE thromboprophylaxis during the COVID-19 pandemic. Sustained improvement will require vigilance in the event of a second-peak. In 2019, a novel coronavirus was identified and a global pandemic was declared in March 2020. Aerosols generated by medical procedures are one route for the transmission of the COVID-19 virus. Pulmonary function tests (PFTs) are considered an aerosol generating procedure (AGPs) (1) and this has had a significant bearing on service delivery. Comprehensive needs assessment was undertaken to measure what changes were required to allow the provision of PFTs to continue safely. Retrospective data analysis of waiting times and influence on patient care pre and post introduction of changes has been collected. The number of air changes per hour required was assessed to be 6. This led to adjustments being made to our extraction and filtration systems. Alterations were also made to PPE recommendations and cleaning procedures. These changes in procedure have reduced the capacity of the PFT laboratory and have led to a significant increase in waiting times. Improvements to current protocols are allowing us to perform PFTS in a safe manner. This will enable us to provide a comprehensive service to our patients once again. Impact of increased waiting times can be lessened with adjustments to work practices. 64% were hypoxic and of those 38% required greater than 10 litters of oxygen (>10L-O2). 8 patients required continuous positive airway pressure (CPAP), 5 were invasively ventilated and 3 were placed on high flow nasal cannula (HFNC). All except 1 patient requiring >10L-O2 that wasn't ventilated or placed HFNC died. The mean length of stay (LOS) in days for non-hypoxic patients, 5.9, >2L-O2: 9.6, >10L-O2: 6.4, HFNC: 11, CPAP: 13 and invasive ventilation: 24. This study showed a prolonged LOS for patients that were invasively ventilated, whilst the need for CPAP had a LOS close to half that of invasive ventilation.

common symptoms were fever and cough. Pneumonia and acute respiratory failure were the direct cause of death in 37 patients, and 25 patients had other causes of death in conjunction with COVID. 61 patients had evidence of infective changes on their admission chest X-ray (CXR). Lymphopenia was present in 72.5% of the patients on admission. D-Dimer done in 53 out of the 69 patients was elevated. Interleukin-6 was only done on 18 patients and was elevated in all of them. Procalcitonin was raised on 34 patients (49.3%). 22.6% of all confirmed COVID-19 cases in TUH died, mostly elderly frail patients, more male than female with severe disease and radiological findings on their CXR and 8 were admitted to ICU. 

Covid-19 has led to a radical change in the way we practise acute hospital medicine. Suspected COVID-19 cases require isolation and a nasopharyngeal swab which is putting pressure on our hospital systems.

To establish the underlying diagnosis of suspected but ultimately negative COVID-19 cases and if the patient was appropriately placed on the COVID-19 pathway. We aim to better understand non-covid presentations to an acute hospital during a pandemic. A retrospective analysis of all admissions documented as suspected COVID-19 was carried out using Cork University Hospital's online system to review discharge summaries (n=402). Patient demographics, symptoms, investigations, and length of stay were collected and analysed.

There was an average of 4.37 suspected COVID-19 cases per day. 74.6% of swabs were taken due to respiratory symptoms. 90.8% of patient were correctly placed on the COVID-19 pathway. The average length of stay was 8.7 days. In total, 64.5% of patients had a final diagnosis of a respiratory illness.

Those who are admitted with suspected COVID-19 have a huge impact on inpatient numbers and the availability of isolation rooms. In CUH, there was 283 more respiratory related admissions over a 3-month period in 2020 compared with the same period in 2019. We report a case of pulmonary Covid-19 infection unusually presenting with acute splenic infarcts and pulmonary emboli. We believe this is potentially among the first published cases to include contrast-enhanced imaging of splenic infarcts in this condition. There is a growing body of published evidence that complications of Covid-19 are not limited to the pulmonary system. [1, 2] To our knowledge, this is the first reported clinical image case of pulmonary Covid-19-related splenic infarcts. During these unprecedented and overwhelming times of uncertainty of disease manifestations, clinicians of all specialties including our surgical colleagues should be aware of a wide range of thrombotic and disease spectrum manifestations of pulmonary Covid-19 infection to include splenic infarctions in the differential diagnosis of an acute abdomen. COVID-19 profoundly affected healthcare services and their utilisation. It has been hypothesised that COVID-19 is associated with increased risk of pulmonary embolism(PE). We assessed how COVID-19 pandemic affected CTPA  utilisation and if more PE were diagnosed in COVID-19 positive patients  Data for patients who underwent CTPA between January-May 2020 were  analysed, including; age, sex, COVID-19 status, WCC, CRP and D-dimer. COVID-19 status was coded as Non-COVID pathway(NC), SARS-CoV-2 Despite high attendance at NIV education sessions, the response rate to the questionnaire by doctors was low despite various strategies to improve this. Completing the evaluation at practical classes may yield higher response rates. Class based education was the preferred format of training but videos were the preferred resource for local information out-of-hours. This highlights the value of using technology to supplement the traditional class based approach to NIV education. 

A cohort of patients admitted to CUH with COVID-19 were identified as being appropriate for a supported discharge service. Patients were educated on home pulse oximetry and uploaded SpO2, HR and breathlessness scores onto the PatientMpower application. A physiotherapist reviewed the data daily, phoned the patient and gave advice on exercise, oxygen management, pacing, energy conservation and secretion clearance. A patient satisfaction questionnaire was completed following discharge from the service. Over 12 weeks, 15 patients had a supported discharge. Readings were monitored 385 times and 176 phone calls were made. Advice was provided on exercise 32 times, oxygen 22 times and secretion clearance 7 times. 58 SpO2 readings were recorded outside the acceptable range and a readmission was triggered for three patients (20%) for inpatient management. 100% of questionnaire respondents reported that the service met their needs and 90% agreed that the service had a positive effect on their recovery. 88% of the respondents who had received daily phone calls felt that this was more helpful than the objective monitoring aspect of the service. A supported discharge service including remote monitoring and regular contact with healthcare professionals can facilitate timely, safe and successful discharges of select patient groups. Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome is an on-going global health emergency. This pandemic became a reality for UHL in March 2020. Here we discuss the respiratory service and how the respiratory department managed the challenges during a pandemic. Reconfiguration of the respiratory service was central to an ongoing service in challenging times. The aim of this review is to explore the changes that were made to deal with the pandemic and how this impacted the ongoing respiratory service. A retrospective review of what was required to manage Covid 19 outbreak within UHL. The respiratory nursing service which consisted of CNS x 3 and RANP x 1 following initial redeployment were given the task of managing educating all healthcare workers with safe practices in managing non-invasive ventilation and oxygen. While ensuring strict infection control guidelines and evolving Covid 19 guidelines. Identification of the safest and highest quality systems for delivering non-invasive ventilation (NIV) which required modification of NIV and AIRVO masks and circuits. This involved investigating and sourcing consumables such as appropriate viral filters to protect the healthcare worker by the respiratory nurse service. Careful consideration of hospital oxygen supply and demand had to be reviewed daily to ensure supply and availability in the system. 820 healthcare workers were upskilled and educated on the practice of non-invasive ventilation and safe administration of high flow oxygen. Clear guidelines were created in conjunction with the ITS guidelines and accessible to all healthcare workers within UHLG on a local platform. Respiratory outpatients continued throughout the pandemic with a lot of the practice on a virtual platform. Overall, healthcare workers were up skilled and practiced safe administration of non-invasive ventilation and high flow oxygen administration during a pandemic in clinical areas where this practice was unknown. A new and evolving service has being identified to ensure respiratory service continue. There is increasing concern amongst clinicians of a possible increase in venous thromboembolism (VTE) events in patients with COVID-19 pneumonia. There remains limited data defining the incidence of VTE in this population and thus also a paucity of research examining the impact of targeted treatment in patients with thrombotic complications of COVID-19. We examined the number of symptomatic VTE events amongst proven COVID-19 pneumonia patients admitted to our institution, a tertiary level academic hospital, over a one month period from 23 rd March 2020 to 23 rd April 2020. Patient characteristics, admission and discharge inflammatory and coagulation markers were included in the analysis. 61 patients were identified, with a male predominance at 61%. All patients were commenced on thromboprophylaxis on admission. 12/61 (19.6%) of patients admitted with COVID-19 were treated for a suspected PE. Of these patients, 3 patients were discharged on anticoagulation, in the form of apixaban, 3 died and 6 remain inpatients. COVID positive patients with disease severe enough to have warranted admission to an acute hospital are at increased risk of VTE and that this risk may extend beyond the period of admission. Further research examining the role of extending the duration of anti-coagulation in COVID-19 patients beyond hospital discharge is now warranted. CoViD-19 is a disease caused by the novel coronavirus SARS-CoV-2 and has a significant impact on healthcare systems worldwide. It places a tremendous burden on hospital bed capacity and in certain countries, has overwhelmed the entire healthcare system, contributing to significant mortality rates from the disease. An early discharge pathway was initiated by HSE with remote monitoring of patients with mild to moderate CoViD-19 disease. We carried out a safety and feasibility evaluation of this supported discharge pathway. We retrospectively analysed all patients who were enrolled into this pathway. After initial assessment, suitable patients are discharged within 24 hours of presentation to hospital with an oxygen saturation monitor. Oxygen saturation is checked twice daily and this information along with the heart rate is recorded on to the application on the patient's smart phone. This information is then available for review by a remote monitoring team consisting entirely of healthcare staff. A drop in oxygen saturation level below 93% is considered significant and an early indication of deterioration, at which point a text alert is sent to the medical consultant on call. The patient is then contacted by phone and if appropriate, advised to self-present to the Emergency Department for a medical re-evaluation. We evaluated the readmission rate to hospital and the number of unexpected deaths in patients on this pathway. 71 patients were enrolled into the early discharge pathway. Patient demographics are listed in Table 1 . Readmission rate to hospital was 4.2%. There were no deaths recorded in this patient group. The average initial length of stay in hospital was 1.9 days and the average number of phone calls made to patients was 1.1 calls per patient.

In conclusion, the early discharge pathway is a safe discharge option that significantly reduces hospital LOS, thus protecting the healthcare system during this pandemic. Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) has delivered transformative improvements to the lives of people with mild to moderate cystic fibrosis with at least one Phe508del mutation (1, 2) . The effects of this drug combination are not yet well understood in patients with severe disease.

We conducted a single-centre observational study with a cohort of patients who received (ELX/TEZ/IVA) as part of a managed access programme if they had either severe lung disease (ppFEV 1 <40%) or were awaiting lung transplantation. Multiple outcomes were measured and compared with baseline data. Paired student T-test was used and a twosided p-value of <0.05 was considered to be significant.

14 patients were included in this analysis. (Figure 1 ). This therapy is expected to greatly improve the disease trajectory for many CF patients with at least one Phe508del mutation and this expectation should also apply to those groups with more advanced disease. LAM is a rare disease 2 , however correct diagnosis is important as it has implications for lifestyle modification and there is effective therapy available. With at least 27 patients identified in Ireland, this represents a prevalence of 11.2 per million women, and is likely higher than this both in Ireland and worldwide. increasingly recognized as highly heterogeneous but a consensus on the subpopulations present in the lung, and discriminative for each subtype, remains elusive. We completed scRNA-seq analysis, and re-analysis of publicly available datasets, of mesenchymal cells from the post-natal, adult and the aged fibrotic lungs of humans. We delineated the transcriptome of lipofibroblasts, myofibroblasts, pericytes, mesothelial cells, smooth muscle cells, and a novel population delineated by Ebf1 expression. Comparative analysis of murine and human lung mesenchymal cells revealed homologous subpopulations with conserved transcriptomic signatures.

We demonstrated that all mesenchymal sub-populations, not solely myofibroblasts, contributed to the expression of extracellular matrix genes in fibrosis. We did not observe evidence of transdifferentiation between fibroblast subtypes in fibrosis. Rather these data suggest that mesenchymal fate decision occur during embryonic development and the identified subtypes remain distinct into adulthood and in the aged healthy and fibrotic lung. This analysis challenges long held beliefs on the contribution of fibroblast subtypes to fibrotic lung disease and provides a basis for definitive identification of the different mesenchymal populations in development, heath and disease. We instituted a strict admission pathway with the aim of establishing and maintaining a Covid-free environment. A rigorous anaesthetic and intraoperative protocol was established to limit aerosolisation risk. Postoperative management was based in individual patient rooms with a standardised recovery pathway. Overall case volume and mix was maintained with stable morbidity and mortality. This approach facilitated the maintenance of a 'Covid-free' high volume high quality thoracic surgical oncology programme during a time of unprecendented disruption to the Irish health service.

Complications of bronchoscopy in a major teaching centre. Incidence of major complications secondary to transbronchial biopsy was 8 (1.6%), (including 6 pneumothoraces (1.2%), 2 with significant bleeding (0.4%)), 5 patient had complications secondary to endobronchial biopsies (0.8%) (3 pneumothoraces (0.6%), 2 with significant bleeding (0.4%)). Only 3 patients with pneumothoraces needed chest drain placement, the remainder were managed conservatively; bleeding complications were treated with cold saline +/-adrenaline during the procedure. All the patients who suffered pneumothoraces required hospital admission, duration of stay was 2 (+/-1) days and mortality rate was 0%. This study shows that bronchoscopy is a safe method with low to moderate incidence of complications and mortality. We believe that preparation, experience and continuous training of trainees and nursing team play a fundamental role in reducing the incidence of complications. Conflict of interest: None to Declare. Idiopathic pulmonary fibrosis has a median survival time after diagnosis of 2-5 years. Pirfenidone and nintedanib are well established as first-line therapy in idiopathic pulmonary fibrosis (IPF). The purpose of our study was to look at objective data available to us for our IPF patients who had been started on targeted anti-fibrotic therapy and compare the experience. We reviewed the charts and records of all IPF patients (162) who were treated with anti-fibrotic medication during the period between 1 December 2012 and 30 April 2020 and whose clinical and pulmonary function records were complete for at least a 12-month period.

After 1 year, lung function test parameters of patients treated with pirfenidone and nintedanib had remained stable from baseline with no significant differences in FVC, TLC and DLCO. Nindetanib outperformed pirfenidone in terms of exacerbation rate, radiological progression of disease and adverse drug events over the course of the treatment course evaluated. This study emphasizes that both nindetanib and pirfenidone remain good therapeutic choices in slowing lung function decline albeit in the context of a disease with enduring mortality. Pulmonary rehabilitation (PR) plays a crucial role in the management of symptomatic patients with chronic obstructive pulmonary disease (COPD), improving exercise tolerance and quality of life (QOL) and reducing exacerbation frequency. However, it's place in the management of other chronic respiratory diseases including interstitial lung disease (ILD) is less well studied.

To address this, we retrospectively analysed outcome data from our cohort of non-COPD patients (n=39) undertaking a PR programme between September 2016 and February 2020. Of the 39 patients included, the majority (74%, n=29) had ILD, 17% (n=5) were female and 83% (n=24) were male with a mean age of 71 ±13 years and BMI of 27.4±4.7 kg/m 2 . Twenty-eight patients underwent pre and post PR incremental shuttle walk testing with average walk distance improving by 23.4±63.5 m post PR. Eleven patients were assessed pre and post PR with a six-minute walk test with a mean improvement of 28.6±36.1 m. There were no significant changes in the Hospital Anxiety and Depression Scale or Chronic Respiratory Disease Questionnaire scores pre/post PR. These data indicate that in our of patients with chronic respiratory diseases other than COPD, general PR leads to modest improvement in functional exercise capacity without a significant change in QOL.

The authors have no conflict of interest to declare.

L Kingsmore 1 ; T Scullion 1 ; E Murtagh 1 ; J Burns 2 ; P Minnis 1

Interstitial Lung Disease Service, Antrim Area Hospital, Bush Road 1

The mainstay treatment of sarcoidosis is corticosteroid therapy, which often complicates bone health. We examined all patients attending the ILD clinic with sarcoidosis within 1 year for radiological involvement and axial bone health. Baseline data was collated from 184 patients. 9 patients (5%) had reported evidence of appendicular involvement on imaging. 14% were treated with hydroxychloroquine. Treatment naïve patients tended to osteopenia BMD 0.952 g/cm 2 (T s -1.27), in comparison to treated patients lumbar BMD 1.061 g/cm 2 (T s -0.8). BMD were similar between those treated with low dose prednisolone and combination agents. Stratification by CXR stage indicated similarities between stage 0 and 4 in terms of treatment rates 89% versus 79% and BMD 1.021 g/cm 2 (T s -0.73) versus 1.06 g/cm 2 (T s -0.77). Inflammatory CXR stages 1-3 had a lower treatment rate (53%) and lower BMD 1.00 g/cm 2 (T score -1.19). The majority of patients were sufficient in Vitamin D (64%) at time of testing. There appears to be mechanisms outside corticosteroid induced net bone loss at play in patients with sarcoidosis. This data suggests a link between bone health and active pulmonary sarcoidosis that could not be explained by treatment or vitamin D deficiency. Idiopathic pulmonary fibrosis (IPF) is an irreversible, fatal lung disease with a major impact on patients' quality of life (QOL). Apart from curative lung transplantation, antifibrotics can slow disease progression. We aimed to study patients' perspective about IPF and their treatment experience. A qualitative descriptive study was conducted on 30 IPF patients on antifibrotics (22 Pirfenidone, 8 Nintedanib), attending our specialist ILD service. Telephonic interviews were conducted and structured patient reported outcomes (PRO) were obtained assessing 5 domains; patients' understanding, impact on HRQOL, psychosocial aspects of the disease, patient/carer support from ILD specialist nurse as well as antifibrotics experience and side effects. The framework method was used for qualitative analysis. Key outcome was patients challenged by having an "unknown" (n=12) and "invisible" (n=9) disease. Patient experiences and satisfaction with antifibrotics were fairly positive, and similar for both drugs. Self-reported impact on QOL was the main factor associated with overall medication satisfaction. Hospital Anxiety and Depression scoring was slightly higher in Pirfenidone (3.9) than Nintedanib users (3). Majority of patients stated that a specialist nurse was their main clinical contact for healthcare.

In conclusion, our study provides an overview of the most used PRO measures in IPF to integrate patients' perspective into clinical practice, thus enhancing personalized medicine. Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) is a rare disease typically of middle aged non smoking women, with few cases described. After first recognitition in 1992, the WHO described it as a precursor to pulmonary carcinoid tumours.

Currently there is no consensus on radiological and/or pathological criteria for diagnosis. Herein we aim to describe our experience of DIPNECH in St. Vincent's University Hospital.

A retrospective analysis of 15 cases was performed. Data collected included: Age, gender, smoking status, CT findings, PFTs, treatment and assocaited neuroendocrine tumours. All patients were female with a mean age of 60.2years. 9 patients had respiratory symptoms at diagnosis. 10 patients had lung function tested with an obstructive pattern seen in 40%. CT findings included a dominant nodule(n=7), associated nodules(n=13) and mosaicism(n=5). 13 cases were associated with a pulmonary carcinoid. Treatment included somatostatin analogues and inhaled corticosteroids in 5 and 5 patients respectively. This is amongst the largest studies evaluating DIPNECH patients in a single centre. DIPNECH is a histological diagnosis, often asymptomatic and therefore underdiagnosed. Obstructive symptoms and lung function were most commonly seen. Given its rarity and current lack of evidence based guidelines a specialist centre is most appropraite for managing such patients. Nintedanib has been shown in both clinical trials and real world experience to be a well-tolerated treatment that slows the rate of progression in Idiopathic Pulmonary Fibrosis (IPF). The most common adverse event reported is diarrhoea, occurring in 50-65% 1 . Experts report that approximately one third of patients discontinue antifibrotic therapies because of side effects. In order to better understand our patients' experience and potentially identify factors that might improve tolerability, we reviewed 26 patients (19M, 7F,) with IPF receiving Nintedanib at our institution between 2015 to 2020. They had a median age of 69.50 years and 80.7% (n=21) had at least one comorbidity: 65.3% reported at least one adverse event; diarrhoea 34.6% (n=9), weight loss 30.7% (n=8), nausea 19.2% (n=5), deranged liver enzymes 7.6% (n=2), anorexia 3.8% (n=1), gout 3.8% (n=1). Twelve patients (46.1%) had at least one interruption to treatment, 5 patients (19.2%) continue on a reduced dose and 2 patients (7.6%) stopped treatment completely due to deranged LFTs and diarrhoea. Therefore in our experience the majority of patients who experience a side effect related to Nintedanib therapy benefit from a temporary cessation of treatment, followed by recommencement of treatment at full or reduced dose. Lung cancer occurs frequently in older patients. Previous studies suggest that older patients are less likely to undergo invasive diagnostic testing compared to younger patients 1 . CT-guided lung biopsy is the investigation of choice for peripheral lung nodules to determine pathology and to guide management. The purpose of our study was to investigate the rate of complication post CT-guided lung biopsy in patients aged 70 years and above and compare data to the published literature. Incidence of complications following CT-guided lung biopsies between 2010 and 2020 was retrospectively reviewed for all patients aged 70 and over in our institution. Via accession number on National Integrated Medical Imaging System (NIMIS), the incidence of post-biopsy pneumothorax, pneumothorax requiring intervention and perilesional haemorrhage was obtained. 223 procedures were performed on patients aged 70 years and above. 33(14.7%) patients developed a pneumothorax at 2 hours post procedure of which 10(4.4%) required narrow bore chest drain insertion. Perilesional haemorrhage was noted at time of biopsy in 28(12.5%) patients, one requiring intervention. All incidences are lower than published international complication rates 2 . Compared to international data, our rate of major and minor complications post CT-guided lung biopsy in older patients is low. The reduced number of direct GP referrals secondary to a delay in presentation to GP may at least partly account for the lower number diagnosed with Stage 1 or 2 lung cancer. This is likely to result in a delay in lung cancer diagnosis for many, diagnosis occurring at a later stage, greater burden placed on the healthcare system and ultimately more deaths. There has been a 40% reduction in the total numbers referred to the RALC and 68% reduction in direct GP referrals to the RALC in April and May 2020. This is likely to result in a delay in lung cancer diagnosis, diagnosis occurring at a later stage, greater burden placed on the healthcare system and ultimately more deaths.

2.24. Pulmonary mucosa-associated lymphoid tissue lymphoma-A single center review of the diagnostic approach.

Farrell AM 1 , Farrell SA 1 , Kennedy MP 1 , Henry MT 1 .

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease and diagnosis is difficult, often requiring multiple attempts at tissue sampling. The aim of this review was to evaluate the diagnostic pathway.

A retrospective review was preformed of patients diagnosed with pulmonary MALT lymphoma in a tertiary referral lung cancer center over 9 years. Ten patients were identified and each diagnostic and treatment approach was analyzed. 30% were diagnosed via transbronchial biopsy, two with the assistance of radial probe ultrasound guidance and one with transbronchial lung cryobiopsy of a predetermined CT-guided targeted segment. 70% were diagnosed following surgical biopsy. 40% had localized disease. Diagnosis was not successfully achieved until a large sized tissue specimen was obtained. The implementation of novel bronchoscopy techniques can assist in reducing the number of invasive surgical procedures required to obtain a diagnosis. All cases should be discussed in a multidisciplinary setting prior to diagnostic attempts. Pan-resistance to platinum agents remains a major clinical challenge in NSCLC. Due to the lengthy process of drug design and trial attention has turned to the repurposing of approved drugs within therapeutic resistance. Cancer stem cells (CSCs) have been hypothesised to be the initiating cells of resistance. All-trans retinoic acid (ATRA) is a well-established chemotherapeutic agent in the treatment of acute promyelocytic leukaemia; it induces terminal differentiation of immature cells. We hypothesise that exploitation of the retinoic acid pathway will deplete the CSC population thereby restoring cisplatin sensitivity. The presence of an ALDH1-positive CSC subpopulation within cisplatin resistant (CisR) sublines was confirmed by flow cytometry. Cells were treated with retinol or ATRA and the presence of CSCs reassessed. The functional parameters of proliferation, clonogenic survival and apoptosis were also assessed. Retinol and ATRA significantly depleted CSCs. Retinol and ATRA used in combination with cisplatin significantly reduced proliferation and survival of CisR sublines while increasing apoptosis compared to cisplatin alone. Exploitation of the vitamin A/retinoic acid pathway re-sensitised sublines to the cytotoxic effects of cisplatin. These data suggest vitamin A supplementation or the addition of FDA-approved ATRA to cisplatin-based regimens may be of clinical benefit in overcoming recurrence and cisplatin resistance.

Disruption of Dicer-1, a crucial component of microRNA biogenesis depletes the stem cell pool, indicating a role for microRNAs in the maintenance of stem cells. MicroRNAs play a role in cancer stem cell (CSC) self-renewal, differentiation, resistance and metastasis. MicroRNAs associated with cisplatin resistance and CSC maintenance may be key in targeting the CSC root of resistance. miRNAs associated with resistance were validated by qPCR. An ALDH1-positive CSC subpopulation was isolated using FACS. Expression of the miRNA panel was investigated within CSC populations. Altered miRNAs were inhibited using antagomiRs and stemness reassessed. Expression of the miRNA panel was investigated in FFPE tumour tissue of a xenograft model of CSCs. A 5-miR signature associated with cisplatin resistance was identified across NSCLC histologies. The ALDH1-positive subpopulation was confirmed as CSCs, within this population miR-34a-5p was shown to be upregulated. This result was mirrored within FFPE tissue. Inhibition of miR-34a-5p with antagomiRs did not deplete the CSC population however it significantly reduced the clonogenic capacity of cell lines. These data suggest that miR-34a-5p, while significantly up-regulated within the CSC population, may not play a regulatory role in expression of CSC markers, however it may play a functional role in the survivability of CSCs. The accuracy of clinical staging of non-small cell lung cancer (NSCLC) is crucial in the establishment of both prognosis and treatment pathways for patients. There can be significant discrepancies between clinical and pathological stages (1). We assessed whether the agreement of clinical and pathological stages in a real world context was similar to that of the data collected from randomised control trials (1) . Delays in patient flow through diagnostic imaging can result in an increase in tumour size and stage, so we also assessed whether delays impacted the accuracy of staging of patients in our cohort. (2) We retrospectively collected data on 103 patients who had surgery for NSCLC in 2019. We assessed the difference between overall clinical staging and pathological staging as well as clinical and pathological T and N stages. We then constructed a timeline for each individual patient by analysing the time in days from their diagnosis to their surgery including duration between important timepoints such as PET scan and date of biopsy and EBUS. Results are summarised in figure 1. There is agreement in the overall clinical and pathological stage in 56.7% (n=51) and disagreement in 43.3% (n=39). Median time between date of diagnosis and date of surgery was 50 and 55 days in the agreement and disagreement groups respectively. Median time between PET scan and surgery was 50 days in the agreement group and 65 days in the disagreement group.

In conclusion, the level of agreement in our centre is similar to that of data from randomised controlled trials. Duration between PET scan and surgery may influence the accuracy of clinical staging however we did not identify any other significant delays that contributed. 

EBUS has long been a common diagnostic tool used in the diagnosis of pulmonary pathologies. In the last decade increased interest has been shown in its usage via the oesophagus for sampling lesions inaccessible via the airways known as EUS-B-NA (1). Our centre conducted 6 cases in which we used this modality to biopsy lesions after failing to do so with traditional EBUS due to poor visualisation/unsafe access (Case-figure1). CT guided biopsy was also not a safe option in any of our cases.

The key outcome was the high diagnostic yield of our cases of 100% with no adverse events reported in any case. No patient received sedation above the standard of regular bronchoscopy. Coughing and desaturation seemed less of an issue subjectively during the procedure. We recommend that respiratory specialist training encompasses this modality in Ireland and the UK. This requires an increased number of cases when appropriate to be done in specialised centres as well as stimulated teaching courses. A combined procedure can be carried out in one simple session. All cases were conducted in the COVID pandemic and a reduction in gastroenterology referrals means reduced further delays in diagnosis/treatments for our patients. Table 1 CKD is common in post-transplant patients, particularly in elderly, male populations, with a COPD related single lung transplant. This finding is significant as more study needed to identify the association between these risk factors development of CKD. Conflict of Interest: None.

Dyspnea is a common complaint in patients with end stage kidney disease being treated with dialysis. Symptoms often persist post renal transplant. The aim of this study was to assess a cohort of renal allograft recipients for potential respiratory compromise, hence identifying a potential target for therapeutic intervention. Renal transplant patients under active follow-up in a single tertiary referral center, were asked to partake in this cross-sectional study at time of clinic follow up. Patients who consented completed the Medical Research Council (MRC) Dyspnea Score and performed basic spirometry. An MRC score ≥2 and/or a forced expiratory volume in one second <90% prompted formal clinical assessment by a Respiratory Physician. 103 patients were enrolled in this study. 35% of all patients reported breathlessness and, with the combined evaluation, 56% of all patients warranted formal respiratory medicine review. Following completion of their investigations, 33 patients were found to have an underlying condition accounting for their symptoms. We recommend that structured evaluation utilising the MRC Dyspnea Score and spirometry be incorporated into the routine follow-up of renal transplant recipients, as this study has indicated a substantial burden of disease that is not ascertained by non-systematic clinical review. Furthermore, it may be prudent to consider this in potential renal transplant recipients prior to transplantation. Bronchoscopy with/without fluoroscopy is employed in diagnosis of variety of lung diseases such as peripheral lung masses, focal/ diffuse lung infiltrates, suspected fungal/mycobacterial lung infections. Complications include penumothoraces, bleeding and infections. Whether use of fluoroscopy decreases rate is unclear 1 .At UHL, all transbronchial biopsies are performed without fluoroscopy due to lack of access. we aim to assess safety and rate of complications of transbronchial biopsies without fluoroscopy. In this retrospective study,95 patients underwent flexible fiberoptic bronchoscopy with transbronchial biopsy, for different pulmonary pathologies in last 6 months.44 were male and 51were female. Average age 70 years (+/-11).Of these,51 had transbronchial needle aspirations (53%),57 bronchoalveolar lavage(60%),13 brush biopsies(13.6%). 8(8.4%)patients suffered complications secondary to transbronchial biopsies:6(6.3%)were pneumothoraces,2(2.1%)were significant bleeding.One patient required chest drain insertion while remaind e r o f p a t i e n t s w i t h p n e u m o t h o r a c e s w e r e m a n a g e d conservatively.Patients with bleeding were managed with cold saline +/-adrenaline.Patients who suffered pneumothoraces required hospital admission and mean duration of stay was 2 days(+/-1).There were no deaths.Our results were consistent with a recent meta-analysis showing rate of pneumothorax ranges between 0.4-5.8% in studies with use of fluoroscopy,and 1.5-20.2% without the use of fluorosocpy 1 .

Our study shows transbronchial biopsies without fluorosopy are relatively safe procedure,and fluoroscopy may not reduce the complication risk.Experience and training play fundamental role in reducing complication rates. Conflict of interest: None to Declare. Chest infection is one of the most common complications after thoracic surgery, we aim to investigate the usefulness of intra-operative bronchoalveolar washing to help decrease the rate of postoperative chest infection and predict the causative microorganism. This is a retrospective study including 100 patients who underwent different thoracic surgeries in St. Vincent University Hospital from June 2016 to March 2020. All patients underwent intra-operative bronchoalveolar lavage before beginning the surgery. Also, a bronchial washing sample was sent for microbiological analysis. One hundred patients were included in our study. Out of 100 surgery, there were 16 cases performed by open thoracotomy, 13 robotic-assisted thoracoscopic surgery and 71 cases with video-assisted thoracoscopic surgery. Additionally, there were 53 cases as primary lung cancer, 16 cases as secondary lung cancer (metastasis) and 31 benign cases. Chest infection was noticed in 12 patients (12%). Out of these 12 patients, there were 7 patients (58.3%)have a positive culture from the bronchoalveolar washing. The mean duration of postoperative hospital stay was 6.1 days. Adopting the intra-operative bronchoalveolar lavage in thoracic surgery can decrease the rate of chest infection and predict the causative microorganism. Consequently, that leads to a decrease in the length of hospital stay.

2.39. The use of a 3D printed ultrasound needle guide to aid trainees in developing skills for bedside ultrasound guided fine needle aspiration and core biopsy of phanthom lymph nodes. In the COVID era access to aerosol generating procedures for diagnostics is limited. It has been shown that ultrasound guided fine needle aspiration and core needle biopsy of neck lymph nodes performed by respiratory physicians is safe and accurate to diagnose and stage cancer. A well formed knowledge of neck anatomy and ultrasound is required in order to train physicians to perform this procedure to an accurate and safe level. In order to correctly guide a needle into a lymph node it is necessary to develop hand-eye co-ordination and use knowledge of in-plane or out of plane ultrasound needling in order to hit the target. The Rapid Innovation Unit of University Limerick has 3D printed a first of their kind device specific needle guides for our portable handheld ultrasound systems. This has allowed us to assess the skills of respiratory trainees in performing this procedure on a simulated ultrasound phanthom and then gauge if they found it easier to use the sterile and autoclavable 3D printed needle guide to improve accuracy and safety in performing FNA and core biopsies. None of our trainees had any previous experience in performing this procedure free style or with a 3D printed needle guide. We performed a retrospective review of our lung cancer database for young patients presenting with a new diagnosis of lung cancer in the last 5 years (2015 to 2019). We looked at gender distribution, smoking history, types of cancer and treatment options, and molecular studies. We also compared these results to all lung cancer patients in the national lung cancer registry. There were 16 patients below the age of 50 years diagnosed with lung cancer during that period. The mean age of the group was 43. 50% were male. Adenocarcinoma was present in 56% of our patients, 6.2% had squamous cell carcinoma, carcinoid 18.7%, small cell carcinoma was 12.5% and NSCL-NOS was 6.2%. 68.7% were either current or exsmokers. 68.7% of patients diagnosed had stage 4 lung cancer. 31.2% of patients had surgical resection, 43.7% had chemotherapy, 6.2% had radiotherapy, while 18.7% did not receive any treatment. When compared to national data of all lung cancer patients, the major differences noted included: prevalence of adenocarcinoma -56% in younger group vs 34% in the national data; squamous cell carcinoma 6.2% vs 25%. The other difference was the stage of diagnosis-68.7% were diagnosed at stage 4 in younger population vs 37% in the national data. Conclusion: Young lung cancer patients have a higher prevalence of adenocarcinoma, lower prevalence of squamous cell carcinoma and present at a more advanced stage than older patients. Stereotactic ablative body radiotherapy (SABR) was introduced as a treatment for radically treatable Non-Small Cell Lung Cancer (NSCLC) in Northern Ireland in 2017. The treatment is given in the regional Cancer centre in Belfast (NICC), 70 miles from this District General Hospital (DGH). The aim of this study was to assess patient outcomes and experience since the service was introduced. All patients who attended the oncology unit from 2017 to 2019 at this DGH were assessed. The number of patients diagnosed with lung cancer, numbers treated radically with surgical resection and numbers of those treated with SABR were recorded. Demographic profile and outcome of those treated with SABR was recorded and compared with those who had surgical resection. Patient experience was audited by a Patient Satisfaction Survey. Over the three year period, 115 patients had surgery for potentially curative NSCLC. Eighteen patients underwent SABR in NICC. Mean age for patients who had surgery was 67.1 (range 40-84) Mean age of patients who had SABR was 75.5(range 60-86). Outcome over the 3 year period was similar in both groups. Patient tolerance of SABR was good, follow up arrangements post SABR were difficult because patients had to travel large distances for outpatient clinics. SABR has been well tolerated in this DGH since introduced regionally. Patient tolerance has been good but difficulties remain as regards follow up post treatment. Lung cancer is a leading cause of death worldwide. As regional variation in cancer outcomes is undesirable, understanding the reasons for such is essential to improve care. A retrospective analysis was performed of 584 patients diagnosed with primary lung cancer at the NCCP MDT at St Vincent's University Hospital from 2016-2020. Stage at diagnosis, lymph nodes status, tumour size post resection and outcomes were evaluated and comparisons between patients referred directly through Model-4 Hospital and Model-2/ 3 Hospitals were analysed. Patients referred via Model-2/3 had more advanced stage and increased nodal burden compared to Model-4 referrals ((Stage 4 = 53% vs 30%). There were a higher proportion of squamous cell (33%), and small cell carcinomas (13%) in Model-2/3 patients compared to Model 4 (27% &,8%).Out of 249 surgical resections, patients from Model-2/3 (n=152) had larger median tumour size compared to Model-4 (n=97)( (31.72mm vs. 24.74mm, p=0.026) and more advanced nodal stage (N1:14.5%,N2:9.1%vs N1:9.2%, N2:4.2%)(p=0.249). This study revealed both variation in stage at presentation between regions but also interestingly in patients undergoing surgery for similar stage following PET-CT imaging, post-operative pathology revealed higher tumour and nodal burden. Further research is warranted to determine if this is due to environmental, epigenetic or other factors. PTLD is a complication of transplantation with significant morbidity and mortality 1 . Incidence varies with age, transplant type and immunosuppression 2 . We aimed to examine the incidence and PTLD outcomes in lung transplant recipients. A retrospective review of lung transplant recipients in the National Lung Transplant Unit between 2005 and 2020 was undertaken to identify patients with PTLD.

From 297 recipients, 8 (7 males, 1 female) were diagnosed with PTLD (2.69%). Indications for transplant were cystic fibrosis (n=5, 62%), sarcoid (n=2, 25%) and emphysema (n=1, 12.5%). Median age at transplant was 30. Median time from transplant to PTLD was 10.53 months. Median age at diagnosis was 35. All were on immunosuppression at the time of diagnosis. The majority had monomorphic PTLD (n=5 Diffuse Large B-Cell, n=1 Burkitt, n=2 polymorphic). 37.5% had bone marrow involvement. 25% had central nervous system involvement. Immunosuppression was reduced in all. 75% received rituximab, 37% received chemotherapy (n=1 R-epoch, n=2 R-chop), 12% received radiotherapy and 1 died prior to treatment. One-year survival was 62.5%. One experienced recurrence at 21-months. This highlights the incidence and outcomes of PTLD in lung transplant recipients in Ireland which are in keeping with international studies 1,2 . Table 1 ). Dose reduction/termination of treatment were higher in the Pirfenidone group.

In the Pirfenidone group, the 6-month mean % reduction of FVC and DLCO in the full dose vs reduced dose was FVC-2.5%, DLCO-0.1% versus FVC -0.7%, DLCO -3.4%. In the Nintedanib group, the % reduction was FVC -6.2%, DLCO -3.3% vs FVC -1.5%, DLCO -11.6% full and reduced dose respectively.

The Nintedanib group appears to experience less side effects. Dose reduction in Nintedanib appears to impact 6-month followup PFTs negatively more than Pirfenidone. There are limitations to our study due to relatively low numbers. (1) Respiratory Department, Beaumont Hospital, Dublin 9.

Lung cancer is the leading cause of cancer related deaths worldwide and late diagnosis is a key contributor to poor outcomes. There is considerable international concern on the effect of the COVID-19 pandemic on cancer services. Our objective was to determine any delay in lung cancer referrals to the Rapid Access Lung Cancer Clinic (RALC) due to COVID-19 pandemic.

We compared referrals to the RALC service at Beaumont Hospital and subsequent diagnosis of lung malignancy in the six-month periods January-June across 2018, 2019 and 2020. In 2020, there was 20% reduction in outpatient referrals (165 to 129). Average number of cancer detected per month since 2018 is 10 cases but this number dropped to 1, 5 and 6 in April, May and June 2020 respectively, coinciding with the peak of COVID-19 pandemic. Simultaneously, 30 inpatient cases were diagnosed in 2020 compared to 12 and 7 cases in 2019 and 2018 respectively. Of the new outpatient diagnosis, 8/11(70%) were stage IV, compared to 14/33(42%) and 9/36(25%) in the period April to June 2019 and 2018 respectively. These differences were statistically significant (p<0.0141 and p<0.0094 respectively). Questionnaire data obtained shows that 30% of patients reported delay in presentation due to COVID-19, related to delay in visiting GP, delay in receiving hospital appointment or cocooning. The COVID-19 pandemic has led to a significant delay of lung cancer diagnosis in some patients. The proportion of inpatient lung cancer presentations increased during the COVID-19 pandemic with symptomatic Stage IV disease accounting for this finding.

Graph shows the trends of lung cancer referrals and diagnosis during COVID-19 pandemic We also analysed the outcome of the CTPA based on the documentation and whether they were present in the order. We also analysed whether the orders were from the ED or the wards and whether they differed. Both reference values for each patient were analyzed using both reference equation sets and the average percentage difference between the two was calculated. The impact on clinical classification of the severity of DLCO was also investigated. An average difference of 12.23% between reference values was found in females, and 5.42% in males. This demonstrates that the ECSC percentage predicted values were lower than the GLI, with potential for over diagnosis. These results were clinically significant as the difference is greater than 5%. Hence, an average of 23% of females and 8% males were misclassified based on their severity of DLCO.

In conclusion, a clinically significant difference exists between the ECSC and GLI reference equations. Respiratory departments should strongly consider changing to GLI (2017) to avoid misdiagnosis. 

The characteristic imaging features of thoracic sarcoid are well recognised and include bihilar and mediastinal lymphadenopathy, perilymphatic pulmonary micronodules and pulmonary fibrosis. However, atypical features occur on CT imaging in up to 30% of cases 1 . We present a case series of nine patients with atypical CT appearances of thoracic sarcoid from the respiratory chest conference at a tertiary referral centre. Histological confirmation of the diagnosis was made in all cases. Unilateral hilar adenopathy was an incidental finding in two cases of thoracic sarcoid without respiratory symptoms. Large pulmonary nodules were seen in three patients, two of whom presented asymptomatically. Biopsy of these nodules subsequently confirmed pulmonary sarcoid. Wedge-shaped and patchy ground glass airspace opacifications were imaged in four patients who presented variably with dry cough and dyspnoea and had ultimate histological confirmation of sarcoidosis. The imaging features of bilateral hilar and mediastinal adenopathy with/without pulmonary parenchymal micronodularity are characteristic for the disease and present in approximately 70% of patients 2 . However sarcoidosis is coined "the great mimicker" due to its many ambiguous forms of atypical imaging features as described. Recognition of the atypical CT appearances of the disease is relevant for treating physicians and radiologists. In all cases a trial period of carinal stenting was performed successfully. Extracorporeal membrane oxygenation (ECMO) was used electively in one case. Each patient enjoyed symptomatic improvement demonstrating the suitability of these patients for surgical airway stabilisation. Carinal stenting is not a long term solution for these patients given the associated iatrogenic symptoms. TBP is an invasive procedure involving the plication of the redundant posterior membranous wall using a polypropylene mesh through a thoracotomy incision. It requires thorough pre-operative work-up, careful patient selection, optimisation of any overlap conditions. International experience has demonstrated good long term results including; symptom improvement, prolonged airway patency and improved quality of life.

There is a cohort of Irish patients that warrants work-up for consideration of TBP.

Birt-Hogg-Dube Syndrome (BHD) is a rare autosomal dominant disorder resulting from mutations in the FLCN gene. It is characterised by pulmonary cysts, fibrofolliculomas of the skin, and increased risk of spontaneous pneumothorax and renal malignancy. The clinical presentation of this disease is variable, even within families. The clinical and genetic characteristics of a cohort of patients attending a single referral centre in Ireland were assessed. 16 patients, 11 of which came from 3 families, were included for analysis. 10 patients were female (62.5%). Median age was 50.5 years (range:19-86). 2 were current smokers (12.5%), 4 ex-smokers (25%), and 10 never smokers (62.5%). All had FLCN mutations confirmed, the most common mutation was C.17_21delCTCTC. 9 patients (56.25%) had had at least one spontaneous pneumothorax and one patient had suffered spontaneous pneumomediastinum. Most patients had pneumothorax aged 30-35. 8 patients (50%) had fibrofolliculomas. No patient had any renal tumour. BHD is a rare condition which can result in variable clinical presentation, even in families with the same genetic mutation. Studies such as this add to the understanding of the complexity of this rare disease. We aim to define the natural history in a larger cohort. There was a statistically significant longer survival in the bulbar group who used and were compliant with NIV compared to those who did not use NIV (p=0.02). Bulbar onset MND had worse SNIP and peak cough flow at diagnosis. We found a significantly longer survival with the use of NIV in those with bulbar onset MND but this was not reflected in the patient cohort as a whole. Pulmonary embolism (PE) is a significant cause of death and morbidity, 5% of all hospital deaths are attributable to PE. Prompt recognition and treatment are essential for minimizing the mortality and morbidity associated with PE. Lysis decisions remain challenging for physicians. In massive PE, with haemodynamic collapse, the robust evidence base for the administration of fibrinolysis is well defined. However, there has been considerable debate on the benefits of lysis in sub-massive PE as evidenced by the Peitho trial (1) We are nearing completion of a comprehensive trust wide protocol to help guide these decisions whilst still allowing an individualized approach to patient care. This protocol involved evidenced based analysis and inter-departmental collaboration. An extensive teaching programme on the protocol has been implemented prior to its trust-wide roll out. Our work on this project has highlighted the complexity surrounding decision making in critically ill patients who are being considered for lysis. Our protocol sets out comprehensive guidance which is evidence based to help standardize patient care. Pulmonary arterial hypertension (PAH) is a severe pulmonary disease which is more common in women. Sex hormone independent mechanisms were recently shown to contribute to the higher incidence in females but the specific mechanisms are unknown. Pulmonary endothelial cell abnormalities are central in the development of PAH and hypoxia is one of the stimuli that leads to these abnormalities. The aim of this study was to test the hypothesis that female predominance in PAH is due to different endothelial cell responses to hypoxia compared to males, which are independent of sex hormones. Human pulmonary microvascular endothelial cells (HPMEC) from 3 male and 3 female age matched donors were placed either in normoxia or hypoxia (1%O 2 , 24/48 hours). Proteomic data analysis revealed pathways that were enriched in females compared to males in hypoxia: "hypoxia", "KRAS signalingDn", "glycolysis", "MYC targetsV2", and "spermatogenesis". Proteins that showed sex-dependent responses included thymosin-β 4 and glucose-6phosphate-1-dehydrogenase, which X-chromosome linked, and previously implicated in PAH. Proteomic analysis revealed that 1) hypoxic responses of female and male HPMEC are different 2) X chromosome linked proteins may play a role in the sex-dependent differences of HPMEC responses to hypoxia. These factors may contribute to the female predominance in PAH. 

High flow nasal oxygen (HFNO) is used to treat patients with hypoxic respiratory failure. (1, 2) HFNO use must be accompanied by forward planning in terms of whether escalation to critical care is appropriate. (1) HFNO is usually initiated by junior doctors, and we had observed that in this patient group, less than 50% of had an escalation plan determined within 24 hours. Our aim was to promote HFNO awareness, provide educational sessions, design a proforma with emphasis on escalation planning, and collate medical staff and patient feedback.We therefore designed a HFNO proforma which included indication, initiation and weaning, and to include an escalation plan timely countersigned by a respiratory consultant.

We achieved over 80% compliance in terms of use of our proforma indicating escalation planning was both established early and consultant led. This was discussed with the patient at the time. Feedback from the medical staff was positive. Although the majority of patients regarded HFNO comfortable, they were often unclear of its indication. Promoting HFNO awareness and providing educational sessions resulted in a positive and sustained uptake of the proforma. This resulted in both earlier consultant led escalation planning and discussion with the patients and families. Feedback from educational sessions was positive. 

Idiopathic pulmonary arterial hypertension (IPAH) is a devastating illness characterised by progressive pulmonary vascular remodelling, proliferation and obliteration. Prostacyclin therapy is a core component of treatment, as it exerts beneficial pulmonary vasodilatory, antiproliferative, anti-inflammatory and antiplatelet properties. Interestingly prostacyclin analogues are not specific for the prostacyclin (IP) receptor and bind additional prostanoid receptors; this is exemplified by treprostinil, which mediates its physiological effects via a combination of IP, prostaglandin E2 (EP2) and prostaglandin D1 receptors (1) . Outside of the pulmonary vasculature, prostacyclin has diverse functions including a recognised role in gallbladder physiology (2) . In our centre, a total of 50 patients are currently prescribed exogenous prostacyclin therapy for pulmonary hypertension and 8 have recent gallbladder imaging. Gallbladder polyps were identified in 3 of these 8 cases (37.5%) and all of these received prolonged treprostinil (Remodulin) therapy ( Table 1 ). These results are higher than anticipated, as studies have reported gallbladder polyp prevalence between 1.4 -12% in the general population. We describe three cases of incidental gallbladder polyps in patients with IPAH and hypothesize that treprostinil may be implicated in the formation of these gallbladder polyps, due to its specific effects on IP and EP2 receptors and the established role of prostanoids in gallbladder health and disease. The implementation of telemedicine services was necessitated internationally due to Covid-19 restrictions. A guidance document 1 was published on the incorporation of virtual telehealth into oxygen clinics and TUH piloted the first virtual oxygen clinic in Ireland.

Patients on the waiting list were triaged, prioritised and further categorised based on their suitability for a virtual assessment (VA) 1 . VAs took place over the phone and patientMpower SpO 2 monitors were used for remote monitoring. The one minute sit-to-stand test was used in place of the six minute walk test 2 .

The pilot ran over a 3-month period and 66 patients attended the oxygen clinic during this time; 50% of attendances were VAs. Only patients who required an intervention that had to be completed face-to-face attended the hospital. Of the 33 VAs, the requirement for a subsequent face-to-face appointment was low (n=2), highlighting the efficacy of the triage system. Patients who received a VA reported they had no preference regarding virtual or face to-face appointments (n=10) or that they preferred VA (n=23). The incorporation of VAs improved access to the oxygen clinic during Covid-19 and has resulted in a change in practice. Prioritisation, categorisation and VAs will continue to be a vital aspect of waiting list management going forward, with patients only attending for face-to-face appointments if they cannot be assessed virtually. 

In haemodynamically stable patients a systematic approach to assessment should be undertaken to avoid unnecessary investigations. Whenever Pulmonary Embolism (PE) is suspected the pretest probability should be assessed. Meta-analyses suggest that probability scores may have higher specificity and increase the diagnostic yield of CTPA (1) . Despite this they are used incorrectly in up to 80 percent of patients. (2) We retrospectively audited patients who underwent CT pulmonary angiogram (CTPA) for a possible PE diagnosis in our hospital. Data was collected on each patients Wells score, D-dimer, bed days, Investigations and Pulmonary Embolism Severity Index Score (PESI.) Results showed that PE detection percentage was in the range of 14% which is considered below the accepted standards set by clinical radiology. D-Dimers were performed inappropriately in 33% of patients. 70% of patients were found not to have had basic investigations completed. 55.5% of patients admitted to hospital had a PESI score of class 2 or less. Patients continue to have incomplete assessments done prior to CTPA. Pre-test probability scoring has been shown to significantly improve detection rates of PE but continues to be underutilized in clinicians. Furthermore with the use of the PESI score a significant proportion of patients could be managed in the ambulatory setting. The results of this study suggest that a multidisciplinary intervention which reflects service users individualised goals is feasible and positively affects emotional well-being, fatigue and mastery of this difficult symptom. Further exploration is needed to examine duration of effect of the intervention. 

Aneet Kumar 1 , Hidayat Ullah 1 , Hashim Khan 1 , Youssef Guirguis 1 , 1

Oxygen is one of the most common drugs used in the acute care of patients. This study aimed to review CTPA orders made over 2 discreet 7day periods in January (n=38) and May 2020 (n=33) in cases where Pulmonary Embolus was suspected. There orders were examined to evaluate the proportion of CTPA orders that took D-Dimer, Well's Score or both into account, in accordance with the agreed standard of care. While no CTPA ordered during the study period took both metrics into account, there was a significant increase in the proportion of orders that mentioned D-Dimer levels from 24% in January to 58% of orders made in May. The proportion of orders that included a Well's score fell from 15% to 3% from January to May. While there was an increase in the proportion of orders that recorded D-Dimers, there is still significant room for improvement the ordering of CTPA scans. In particular, when coupled with the negative predictive value of D-Dimer levels, the inclusion of a Wells score could help reduce the burden of unnecessary scans on both patients and the radiology departments across the HSE. There was inconsistency across documentation. In 13(46%) cases, suction was applied however the timing was ambiguous in 4(14%). In 8(29%) instances, the type and size of drain was unclear. There was no documentation of safety advice for 10(36%). Overall, we showed compliance with guidelines but highlighted scope to manage a select group with PTX <2cm as outpatients. Pectus excavatum (PE) is the most common congenital deformity of the thoracic wall, characterised by an inwards turned sternum, resulting in a concave "funnel-like" chest. PE is associated with a wide spectrum of clinical presentations with questionable cardiopulmonary effects and psychosocial concerns re aesthetics. PE is traditionally managed by two main surgical techniques; the open "Ravitch" method and the less invasive "Nuss" method. Due to the potential for major complications and internal organ damage, further less invasive techniques have been developed with a view to reducing post-operative morbidity, decreasing operative times and hospital stay length, and primarily focus on improving cosmesis. Pectus Up is an innovative, minimally invasive set of implants and tools, centred around a new procedure called taulinoplastia, which involves elevating the sternum before securing it with a bioinert plate. Alternatively, a custom made implant, offered by Anatomik modelling, can be inserted superficial to the patient's sternum. Silicone implants are specifically engineered using computer assisted design (CAD), tailored to a patient's unique anatomy based on imaging, and implanted with a superficial, straightforward procedure. A series of patients, following the lifting of Covid19 public health restrictions are undergoing minimally invasive corrective surgery for PE. A review of the evidence base and available techniques including operative videos will be presented.

M Talty 1 , F Gargoum 1 , R Rutherford 1 . 1 Respiratory Dept, Galway University Hospital.

There is a lot of attention given to serially assessing the strength of the inspiratory 1,2 and expiratory muscles in MND patients to try and predict impending respiratory and sputum clearance failure. To our knowledge, there have been no studies looking at the effect of weak respiratory muscles on the patient's ability to clear their upper airway. This can be a distressing symptom for patients and reduce the efficacy of noninvasive ventilation. We, therefore, surveyed our patients by questionnaire to assess their burden of nasal symptomatology. 21 out of 30 (70%) patients responded and consented. 14 (66%), described regular nasal and/or sinus symptoms, occurring ≥ a few times a week. 11 (52%) reported a moderate or greater impact on QoL. 16 (63%) reported difficulty with nasal congestion and an inability to adequately clear their nose, 9 (56%) of whom felt it was due to an inability to generate enough expiratory force. 9 (45%) patients employed NIV, none of whom reported an impact on its use. In this small study we identified a significant burden of nasal symptomatology in our MND population. Topical medications, breath stacking and single nostril expulsion technique could all play an important role in ameliorating this symptom. 1 Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland.

Pneumonia affects around 8 in 1,000 adults each year in Ireland. 1 British Thoracic Society (BTS) Guidelines state that all patients admitted to hospital with community acquired pneumonia (CAP) should have a follow up chest x-ray (CXR) within 6 weeks of being discharged from hospital. 2 The aim of this retrospective audit is to evaluate whether follow-up CXRs were performed on patients admitted with radiologically confirmed pneumonia within the correct time frame as outlined in the BTS guidelines. We randomly selected 100 patients who were admitted via the emergency department in Beaumont Hospital between October 1 st and November 31 ST 2019 with a consolidation evident on their admission CXR. 100 patients were identified, 52% were female 48% male with a median age of 64.5 years. 45% did not have any follow up imaging. 55% did have follow up imaging, of which 45% had their CXR within 6 weeks of discharge, 32.7% within 6-12 weeks, 12 21.8% greater than 12 weeks. 72.7% had full resolution. 55 patients had follow-up chest imaging, with 25 fulfilling the BTS guidelines. This means that potential lung cancer diagnoses/other respiratory conditions may be delayed. Our plan is to educate the importance of follow up CXRs and we plan to re-audit in 3 months. HFNC oxygen therapy (Airvo TM ) delivers humidified and heated air at flows up to 60litres/minute and FiO2 from 21% to 100%. Its use in critically unwell patients with respiratory failure has been increasing rapidly. HFNC reduces the anatomical dead space, provides a mild positive end-expiratory pressure, maintains consistent FiO2 and humidification. HFNC has been shown to be efficacious in hypoxic and hypercapnic respiratory failure, weaning from NIV and reducing the need for reintubation in the ICU. We conducted an NCHD wide survey assessing their knowledge of HFNC particularly looking at indications/contraindications as well as their overall confidence in initiating HFNC prior to implementing a hospital wide policy. 59 NCHDs from all disciplines completed the survey. 26 (44.07%) had previously commenced a patient on HFNC, 33 (59.03%) had not. 12 ( 20.34%) reported they felt confident in initiating a patient on HFNC ,16 ( 27.12%) reported knowledge of the required settings. 57 (96.6%) of respondents reported they would feel more confident initiating HFNC if there was a policy available. Based on the results of our study, a hospital wide policy on the use of HFNC was implemented, including clear indications/contraindications, infection control measures, appropriate settings and a flow diagram outlining monitoring and escalation of care. We will re-audit in three months time.

3.24. Optimum viscosity of a perfusion solution reduces oedema formation in the isolated mouse lung. Intravenous fluid therapy is a cornerstone in the resuscitation of acute hypotensive states. However, resuscitation strategies can cause marked haemodilution, reducing plasma protein concentration, plasma oncotic pressure, and blood viscosity, with subsequent interstitial and pulmonary oedema formation (1). We have recently reported that perfusing isolated murine lungs with a solution with a relative viscosity (RV) of 2.5, adjusted with a biocompatible macromolecule, reduced the rate of oedema formation when compared to a solution with a viscosity lower than blood (RV1.5) (2). We now report work identifying the optimum viscosity of perfusing solutions and demonstrate that the beneficial effect of optimum viscosity solutions is independent of the macromolecules used to increase RV. Mouse lungs were isolated and perfused ex vivo until oedema developed or 180 minutes had elapsed. Perfusion solution with low viscosity (RV 1.5) was compared to higher viscosity solutions (RV 2.0, 2.25, 2.5). RV1.5 comprised Dulbecco's Modified Eagle Medium with Ficoll PM (40g/l) added. Higher viscosities solutions were prepared by adding one of the following high molecular weight polymers: Ficoll PM400, or Dextrans of different molecular weights (>300kDa) at concentrations sufficient to achieve the target RV. Oedema formation was assessed using Wet:Dry weight ratios(W:D). Using Ficoll 400kDa, lungs perfused with solution RV2.5 had significantly lower (P<0.05) W:D than RV2.0. Perfusate with RV2.25 was similar to RV2.5. When perfusates with RV2.5 were prepared using two different high molecular Dextran solutions (>300kDa), W:D was also significantly lower (P<0.05) compared to RV1.5.

Perfusion solutions exhibiting an optimum viscosity (RV2.5) reduced interstitial oedema formation in isolated lungs. This effect is independent of the exact concentrations or chemical structures of the biocompatible macromolecules used to alter viscosity. Further work exploring the potential impact of reduced blood viscosity caused by haemodilution during standard resuscitation protocols is needed. 

Burden of respiratory disease is challenging. Only 1/3 to 1/2 of individuals with airflow obstruction have a formal diagnosis1 Often respiratory diseases are managed in primary care, without access to diagnostics. Early diagnosis and pharmacological intervention are essential in achieving better clinical outcomes for patients. The pilot of an RAU. The unit facilitated early review of patients with suspected respiratory disease and those who frequently exacerbated. The RANP facilitated a full clinical examination with access to diagnostics required. Where possible patients received an accurate diagnosis, education, health promotion and commenced on appropriate medication. 46.5% (n=20) were diagnosed with COPD and commenced inhaled therapy. 14 % (n=6) were diagnosed with asthma and commenced inhaled therapy. 39.5% (n=17) were referred with other respiratory concerns such as; Peamount Healthcare Respiratory Unit offers inpatient rehabilitation for respiratory patients requiring ongoing intervention following their acute stay in Tallaght University Hospital. In 2019, the bed occupancy for the unit was 76%. The purpose of this two-week audit was to review timelines of patient flow from TUH to the unit to identify ways of improving efficiency of transfer and maximising bed capacity. A two-week service audit was carried out identifying number of referrals to the unit, time from receipt of referral to registrar review, acceptance and admission to the unit, and number of communications between sites prior to patient being admitted. Over the two-week period, 9 patients were referred to the unit, 8 were accepted. The time from receipt of referral to review was 0.88 days, from review to acceptance 1.75 days, and from acceptance to admission to the unit 0.5 days. Additional medical information was requested for 5 out of the 9 referrals, and an average of 6.4 additional communications between sites occurred to obtain all relevant information.

The results indicate improvements could be made in ensuring all relevant information is being sent on initial referral to minimise the number of communications and resulting delay in patients being accepted to the unit. Data collection and quality improvement projects are ongoing aiming to maximise bed capacity and improve respiratory care pathways between acute and subacute hospital sector. "Singing for Lung Health" (SLH) 1 when used as an adjunct to managing symptoms in chronic respiratory conditions has the potential to improve health related quality of life and anxiety. This pilot study sought to examine the effects of SLH incorporated into a local standard pulmonary rehabilitation programme (PRP). All participants attending an 8-week PRP between November and December 2019 were invited to partake in an optional once weekly 30minute SLH session. It was conducted over 5 weeks immediately after their exercise training sessions. The SLH session was led by a physiotherapist with a musical background and comprised of warm-up/breath control exercises followed by well-known popular songs. A post intervention participant survey and focus group (n=11) were completed, facilitated by a physiotherapist not involved in the intervention.

Thematic analysis of the results demonstrated improvements in mood, well-being, symptom control & confidence. The participants also reported the experience was fun, enjoyable and social. SLH has the potential to deliver health, psychological and social benefits to people with chronic respiratory conditions and preliminary data from this pilot study supports this. However robust research is required before it can be adopted as an intervention offered routinely to people with respiratory disease. St. James's Hospital, James's Street, Dublin 8.

Patients newly commenced on ambulatory oxygen therapy (AOT) and long-term oxygen therapy (LTOT) are often not followed up to assess appropriateness/necessity of initial prescription [1] . The aim of this audit was to assess the effectiveness and outcomes of a nurse-led clinic at ensuring follow-up of all patients who were newly commenced on LTOT and/or AO following a hospital admission. The audit examined all inpatient home oxygen requests sent between November 2019 -March 2020. Data in relation to follow up attendance and modification of prescription was captured on Excel. Fifteen patients newly commenced LTOT and/or AOT as an inpatient over the study period and were eligible for inclusion in the audit. Only six patients attended the first follow up at six weeks (DNA n= 5; CNA due to COVID n=4). Twelve patients attended a further follow up review at six months. Six persons attended twice and only two had no follow-up. Over the two visits, LTOT was stopped in 4 persons and modified in two, while AOT was also stopped in four persons and modified in two. Nurse-led care allowed for high follow-up rates of patients prescribed home oxygen following a hospital admission and ensured appropriate changes were made.

Low molecular weight heparin (LMWH) is a class of anticoagulants that is frequently prescribed in hospitals. Its various indications include Thromboprophylaxis, treatment of DVT/PE, A.Fib and ACS. This audit aimed to assess whether LMWH is prescribed appropriately in this hospital based on Age, Weight and Creatinine Clearance, and according to HSE LMWH prescribing guidelines. All patients admitted in the surgical and medical wards of Mayo University hospital between 8 th -10 th June 2020 were included. Their drug charts were reviewed, documented weights collected and their Creatinine Clearance (CrCl) was calculated according to the Cockcroft-Gault equation.

Out of 128 patients, 67 (52%) patients were on LMWH. Among them, 94% were on Clexane and 6% were on Innohep. 49 (73.1%) patients were appropriately prescribed LMWH and 18 (26.9%) patients were not. Out of those 18 patients, 10 (55.6%) patients were under prescribed and 8 (44.4%) patients were overprescribed. (7 (38.9%) patients were not prescribed according to weight, 3 (16.7%) patients were not prescribed according to CrCl and the remaining 8 (44.4%) patients were prescribed incorrect dose) These results demonstrate that the majority (73.1%) of patients were prescribed LMWH appropriately. But to achieve maximum compliance and minimise the risk of complications/side effects, on-going education should be provided to NCHDs. Inclusion of the VTE prophylaxis Protocol and specified page for anticoagulation prescription in the hospital's drug chart would be a useful and safe practice. The Oxygen Therapy Clinic (OTC) was established in Louth County Hospital (LCH) in April 2019. Prior to this, patients from North Co. Louth and Co. Monaghan travelled to the OTC in Our Lady of Lourdes Hospital (OLOLH), Drogheda. Being aware of the burden and cost of travel for these patients, we established the OTC in LCH to alleviate this. An anonymous patient satisfaction survey was carried out in March 2020 on the 61 patients who had attended in the year prior. The response rate was 66%. 100% of patients reported increased convenience to have their appointment in LCH rather than OLOLH and would prefer future OTC appointments in LCH. 100% of patients reported that the directions and information in their appointment letter were clear, they had a comfortable, clean area to wait and the nurse/physiotherapist listened to them/their carer. 93% of patients reported their appointment was on time. 98% were satisfied with the treatment/advice. A total of 1932km and over 20 hours travel time was saved for patients by facilitating their appointment in LCH rather than OLOLH Patients from North Co. Louth and Co. Monaghan report preference to attending OTC appointments in LCH saving travel cost and time.

RM Rutherford 1 , D Doyle 1 , J Ryan 1

We examined the adult population of patients with bronchiolitis in GUH to determine common aetiologies and their responses to treatment. There is scant literature outlining the management of bronchiolitis so our data may shed some light on this uncommon disease. Our patient electronic system was interrogated with the search term "bronchiolitis" and 75 patients were reviewed. In a number of cases, bronchiolitis was not specifically reported by a radiologist, but instead found to be a feature present on imaging by a pulmonologist. Two thirds of our patients were female and the mean age at diagnosis was 63. Half of the patients had obstructive pattern on spirometry. Bronchiectasis, obstructive airway disease and reflux/aspiration were the commonest causes of adult bronchiolitis in our cohort. H influenzae was the most common pathogen, followed by P aeruginosa then S pneumoniae. Two thirds of our cohort had repeat imaging and, of these, three quarters showed improvement. The chart below displays which treatment strategies were used and their outcomes. This study was conducted outside a lung transplant centre, so it should be mentioned that lung transplant is a recognised cause of bronchiolitis but not one that was included in our dataset. Campbell, C D. [1] Doherty, M [1] Baker, L [1] Finan, K [1] [1]

Respiratory Department, Sligo University Hospital, Sligo. Polysomnography (PSG) is the gold standard test for obstructive sleep apnoea (OSA), but is resource intensive. Nocturnal oximetry is often used as an initial diagnostic tool in suspected OSA because of its convenience and low cost, but it lacks sensitivity, with consequent long PSG waiting lists. We conducted a quality improvement project to expedite OSA diagnosis, using a novel sleep diagnostic device, the WatchPAT.

To gauge the impact of OSA undiagnosed by oximetry on PSG waiting lists, we initially assessed consecutive PSGs undertaken in our centre in the preceding year. Thereafter, patients awaiting PSG for suspected OSA underwent home sleep testing (HST) using WatchPAT devices, to quantify the proportion of patients that could be spared PSG by the use of more advanced HST. PSG identified a significant burden of OSA not diagnosed by oximetry: 84% of PSG patients an AHI >5 events/hour, with 64% having at least moderately severe disease. 16 subsequent patients with non-diagnostic oximetry had HST: mean AHI was 20.3±16.5 events/hour, 14 (87.5%) were identified as having OSA, with 8 (50%) having an AHI>15.

These data highlight the impact of OSA on PSG waiting lists, along with the role of emerging technologies in expediting OSA diagnosis and treatment.

Patients undergoing PSG Non-tuberculous mycobacterial pulmonary disease (NTM-PD) is increasingly reported in patients with no identifiable risk factors. We sought to characterise the susceptibility of primary macrophages from healthy individuals to Mycobacterium avium (M. avium). Primary monocyte-derived macrophages (MDMs) from 22 healthy volunteers were infected with M. avium (Chester reference laboratory strain) at multiplicity of infection of 0.1-1 for 4 hours, before washing. Supernatant was collected, and cells lysed in 0.2% saponin, to determine extracellular and cell-associated colony counts at baseline and 24-hour intervals. Supernatant cytokines were quantified by ELISA. Statistical analysis was performed using the Kruskal-Wallis test.

There was diversity between donors in the proportion of viable bacteria that was cell-associated at baseline (median 25.4% IQR 15.5-37.8%). Bacterial proliferation was observed in all donor MDMs, with inter-donor variability in growth (Fig. 1) and secretion of IL-6 (median 1306pg/ml, IQR 550-4576pg/ml) and IL-8 (median 9156pg/ml, IQR 5814-17713pg/ml). There was an inverse relationship between IL-6/IL-8 secretion and bacterial growth but this was not significant. Similar findings were observed in two clinical isolates of M. avium.

In conclusion, primary macrophages from healthy donors show differential susceptibility and inflammatory responses to M. avium. Further investigation is warranted to elicit host factors to predict susceptibility to NTM-PD. Pneumothorax is a common presentation to acute healthcare services in Ireland, accounting for 7,045 inpatient bed days in Ireland in 2017. There is robust evidence to demonstrate that ambulatory management of pneumothorax is feasible and safe. This project developed, implemented and evaluated an Integrated Care Pathway (ICP) for patients with pneumothorax that maximised ambulatory management for suitable patients. The ICP was evaluated using a prospective multi-site observational study. At the centre of the study design was an extensive economic analysis of ambulatory management for pneumothorax. Such an economic analysis of the effect of ambulatory management for pneumothorax has not been presented elsewhere in the literature. Thirty two patients were recruited over an eleven month period. Implementation of the Pneumothorax ICP resulted in a statistically significant reduction in inpatient length of stay of 2.84 days from 7.4 to 4.56 days (p=0.001), and thus a per-patient cost saving of 2314 euro. This project has demonstrated that standardisation of care for pneumothorax patients, with a focus on ambulatory management, is economically beneficial for the healthcare service. It is thus anticipated that this work will be used to inform healthcare policy at a national level in Ireland. Sleep disordered breathing and obstructive sleep apnoea are conditions with a high burden of patient morbidity and can have long term consequences for a patient's physical health leading to higher rates of coronary artery and cerebrovascular disease. (1) However in late 2019 with the outbreak of the SARS-CoV2 pandemic and the realisation that spread was predominantly by aerosol a number of major modifications were made to how many procedures were performed. In particular any procedure expected to generate an Aerosol (AGP). This had a profound effect on the diagnostic and therapeutic sleep services within the Southern Trust. In particular continuous positive airway pressure (CPAP). As a result of this there has been a significant change in waiting times for diagnostic sleep studies and for CPAP initiation. This is due to a number of factors; the redeployment of staff, the need for increased sterilisation between procedures and patients and also the advice given to many large groups of patients to "shield" and only leave their homes for emergencies or essential reasons. (2) Improvements to current protocols and work practices have allowed us to re-establish the sleep service maximising efficiency whilst at the same time maintaining staff and patient safety. A retrospective review was performed of patients with severe asthma on biologic therapy (Omalizumab, Mepolizumab, Resilizumab or Benralizumab) in our centre 45 patients were identified and their outcomes prior to and one year post biologic therapy commencement were analysed. 73 patients had been initially commenced on monoclonal therapies in our institution. 45 have continued therapy for over 12 months. We recorded the ACQ score, number of exacerbations, hospital and ITU admissions in the 12 months before and 1 year after commencement of therapy. Antibiotic and steroid use was examined in relation to both exacerbation treatment and prophylaxis. An 80% reduction in exacerbations and a 75% reduction in hospital admissions, with a subsequent reduction of 403 bed days, which was significant (p= 0.04). There has been a 100% reduction in ICU admissions. ACQ was calculated at a mean score of 3.3 pre biologic therapy. A reduction in ACQ to 1.5 a year post biologics (P=0.005).

There was a 50% reduction in the use of maintenance steroids and an 80% discontinuation rate of prophylactic antibiotics (P=0.004) Thus biologic therapy significantly improves patient outcomes and should be considered for suitable patients with severe asthma. Asthma is a common condition affecting 1 in 12 people in Ireland. [1] Asthma exacerbation requiring ICU admission (AE-ICU) is associated with increased risk for asthma death. [2] Our aim was to audit pre-ICU management of patients with AE-ICU at Beaumont Hospital (BH) and identify areas for improvement. Chronic rhinosinusitis (CRS) is an important cause of poor asthma control, yet there is little prospective data on risk factors and impact of CRS treatment. We established a prospective study utilising a combined asthma-ENT clinic to assess this patient group. We report the characteristics of the first 40 patients in this study. Patients recruited from the Asthma clinic in GUH were assessed and managed in a standardised manner using a multidisciplinary team approach. 40 asthmatics (mean age 57 +/-& 21 male) were studied with evidence of CRS (Lund MacKay Score 11+7). By RAST testing (22/39) 56% were atopic (HDM 1; Grass 12; Tree 3; Dog 5; Cat 6) Aspergillus sensitization was seen in 7(17%). 30/39 (76%) had eosinophilia including 12/17 of the non-atopic cases. Other results included ANCA (2); ANA (4); Low immunoglobulins (3) and alpha 1 antitrypsin deficiency (2); aspirin exacerbated (2) . Compared to general asthmatic populations, atopy, while common, is less prevalent in this cohort of CRS in asthma. The strong association with eosinophilia and aspergillus sensitization is noteworthy. Further studies relating to risk factors and management are ongoing in this prospective cohort. To examine self-efficacy among adults with asthma, following a nurse led educational intervention using biofeedback of treatment use. Participants (n=88) who had completed a larger RCT (INCA Sun) took part in this study. Participants were randomised into a control (best practice education) or intervention (best practice education, enhanced with personalised biofeedback) group in the RCT. Biofeedback on inhaler treatment use was generated using inhaler adherence technology, attempted and actual adherence was recorded. An adapted version of the Asthma Self-Efficacy Questionnaire was completed by all participants once. Both study groups had highest mean attempted and actual adherence in month 1 and lowest in month 8. Control group felt most confident in communicating with their healthcare provider, intervention group felt most confident about the use of their inhalers. The highest mean level of overall self-efficacy was reported by the control group; despite this they showed a statistically significant (p=0.003) decline in mean actual adherence between month 1 and month 8. A high level of perceived self-efficacy did not reflect actual behaviour when compared to objective measures of self-management such as inhaler adherence. Biofeedback when incorporated into asthma self-management strategies results in a more accurate assessment of self-efficacy, representative of actual behaviour. This information can be used to deliver personalised asthma and selfmanagement education, ensuring effective asthma management. Although the short-term benefits of pulmonary rehabilitation (PR) are well established in chronic obstructive pulmonary disease (COPD), long-term benefits remain unclear. This study aimed to examine i) if those who participated in communitybased exercise in a peer support group (SG) were more likely to maintain exercise capacity and health status at 12 month follow-up and ii) perceived barriers and facilitators to participation. Participants presented with COPD and previously completed an 8-week PR programme. Participants were encouraged to participate in SG following PR. Pre-PR, post-PR and 12-months outcomes included the ISWT, CAT and secondary measures of anxiety, depression, lower limb functional capacity and gait speed. Benefits and barriers to participation in SG were assessed using a questionnaire. Participants (n=19) endorsed the benefits of the SG. Barriers included accessibility, transport and timing of sessions. Mean changes at 12 months showed significant, clinically relevant between-group differences in favour of SG for exercise capacity, gait speed and anxiety (all p < 0.05). SG are endorsed by participants with COPD, and can offer a potentially innovative and efficient model for maintaining exercise capacity and health-related quality of life gains following PR. A larger, multicentre, randomized controlled trial is warranted to further explore the promising results of this study. Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide. Oxygen therapy is an essential component in the acute management of COPD exacerbations but there is a risk of triggering hypercapnic respiratory failure. Oxygen should be prescribed to achieve target saturations (Sp02) of 88-92% to prevent adverse outcomes 1 .

To investigate in-hospital adverse events related to excess supplemental oxygen in COPD patients with chronic hypercapnia (PaC02 > 6.0kPa).

A study of 50 hypercapnic COPD patients admitted to hospital between September 2019 and January 2020. Data including demographics, blood gases, Sp02, and in-hospital adverse events were collected retrospectively from medical records. Patients on LTOT were excluded. Adverse outcomes included decompensated type 2 respiratory failure (T2RF) requiring BIPAP and intensive care unit admission. 21(42%) were male and 29(58%) were female. Mean age was 68.7 years. 40(80%) patients had their target Sp02 range charted. Out of these, 23(57%) received over-oxygenation and 7 (30%) required BIPAP and 4(17%) were escalated to ICU. Out of the 10(20%) who did not have parameters charted, 6 (60%) received over-oxygenation without any adverse events. Despite the important role of palliative care (PC) in the management of patients with chronic obstructive pulmonary disease (COPD), it is frequently under-utilised and is not offered to the majority of patients with advanced disease 1,2 .

To examine the utilisation of PC services in the cohort of patients supported by the COPD Outreach Service in St Michael's Hospital, a retrospective analysis of the service from July 2019 to July 2020 was performed. The majority of patients had attended the emergency department and/or been hospitalised with a COPD exacerbation in the preceding year, markers of poor prognosis. A total of 168 patients engaged with the service during this period, with ten deaths occurring (5.9% mortality rate) half of which were attributed to COPD. Chart review of deceased patients' medical records revealed 50% had severe disease based on spirometric criteria and overall 70% of them had been referred to PC services. This finding is encouraging, given the low overall PC referral rates reported 1,2 . This and the low mortality rate in the cohort may be related at least in part to the involvement of a COPD outreach team providing support and continuity of care for individuals with advanced COPD in the community.

Global best practice guidelines recommend access to a pulmonary rehabilitation programme, as it provides long-term benefits for COPD patient's, their quality of life and the overall functional abilities. In addition, there is a proven reduction in hospital admission rates (GOLD 2020, The data analysis indicates that tele-pulmonary rehabilitation appears to provide a reduction in hospital admission rates of COPD patients. In addition, the studies indicate a positive impact on reducing hospital costs and increasing functional/physical assessment scores and medication/ inhaler adherence. The current COVID-19 pandemic has focused greater attention on the need to have virtual tele-pulmonary rehabilitation as part of standard practice in the provision of "business as usual". More studies are necessary to further substantiate these findings prior to the development of standardised, evidence based virtual tele-pulmonary rehabilitation systems.

O'Connor A 1 , Hayes C 1 , Long D 1 , Costello RW 1,2 , Ryan DM 1,2 .

(1) Respiratory Service, Beaumont Hospital, Dublin (2) Royal College of Surgeons in Ireland, Dublin.

Asthma is common, affecting 1 in 13 people in Ireland (1). 60-70% is uncontrolled, with an associated increased risk for death (2) . In Beaumont Hospital (BH), we recently audited asthma standards of care (SOC) for ward and ICU admissions. We now proceed to an audit of asthma deaths. Asthma deaths occurring between January 2010 and February 2020 were identified using the Hospital In-Patient Enquiry (HIPE) system. An audit pro-forma was designed evaluating asthma SOC, against National Clinical Effectiveness Committee Guidelines (2015). HIPE confirmed approximately 80 asthma admissions per year (3% ICU) to BH and four in-patient asthma deaths during 2010-2020 (0.5%). Median age 63 (34-86) years, 3/4 (75%) female, 3/4 (75%) non-smokers, 1/4 (25%) prior ICU admission, 3/4 (75%) multiple co-morbidities, 1/4 (25%) intubated and died in ICU. Median time to death 3 (2-13) days. Disappointingly, there was no peak flow (PEFR) monitoring performed (100%) and steroid dosing was inappropriate (75% exceeded, 25% below guidelines) (see Table) . Asthma death following admission to Beaumont Hospital is rare. Asthma deterioration was early, similar to our ICU cohort. There were no differences in standard of care between patients who survived or died following asthma exacerbation. Aspirin sensitivity is one of the hallmarks of Samter's triad, and is present in up to 14% of patients with severe asthma.(1) NSAID-exacerbated respiratory disease (N-ERD) is a chronic, eosinophilic inflammatory condition, occurring in those with asthma, chronic rhino-sinusitis, nasal polyps and symptom exacerbation associated with NSAID use. Aspirin challenge has been established with the aims of both confirming aspirin hypersensitivity in asthma, while aspirin desensitization has been shown to have a role with regard to treatment.

(2) A one-day aspirin challenge and desensitization programme was established in TUH in 2018. Since establishment, this programme has treated 15 patients with an aspirin change and, if successful, subsequent aspirin desensitization. This retrospective cohort study assesses for improvement in symptoms, exacerbation rate, and need for rescue medications following desensitization. Aspirin desensitization in N-ERD has shown promise as a safe method to reduce symptom burden and glucocorticoid prescription. Initial data from our service, presented at this conference last year showed that 80% of The wide range of asthma medication can be confusing to both the patient and the physician. The asthma inhaler poster helps patients, physicians and healthcare professional identify the correct asthma inhalers. This poster assists you to identify the name of the inhaler, the strength of the inhaler as well as spacer devices. It can be an excellent tool for patients attending an outpatient appointment and scheduled or unscheduled healthcare visit. The poster can assist the health care professional identify the correct medication dosages and aiding decision making on stepping up and down of the inhaled medication to ensure optimum asthma control. This is the 4 th edition of the poster and is a collaboration between colleagues in Tallaght 

With effective inhalers, we are observing fewer acute asthma presentations to GUH. Accordingly, the expertise in managing these presentations has probably deteriorated. Therefore, we audited this critical phase of emergency management in our ED. A retrospective list of asthma presentations between January 2019 and May 2020 was generated. Paediatric and obvious non-asthma patients were excluded. A sample size of 20 patients was selected. The records of their investigation and treatment were examined and compared with standard care outlined by the BTS guidelines 2019. Among our results we found that only 11 of 20 patients received nebulised salbutamol 5mg as first line therapy. The mean time from review to administration of nebuliser was 21 minutes. Only 6 of 20 patients had their severity scored. 11 of 20 patients had their PEFR scored. 2 patients with SpO2 ≤92% did not have an ABG. Our audit identified areas for improvement, in particular with respect to the recommended first choice of nebuliser. Severity should be calculated because it is a useful guide to management. We aim to plan simulated training for ED and medical staff as well as create a management algorithm before re-auditing. We report the attrition rates from an eight month, prospective RCT (INCASUN). Patients were randomized into two groups; group one personalized biofeedback, group two standard care. Patients attended the research facility monthly. Various retention strategies were implemented in this study such as; building rapport with the study team, no waiting times, telephone reminders and paid parking. Four sites had an attrition rate of 0%. 20 patients withdrew from the six remaining, with an overall attrition rate of 9%. Between site difference was observed, suggesting strategies implemented reduce attrition rates. The lowest attrition rate was seen in the biofeedback group (25%) demonstrating that patient engagement in their own care is an important factor. Lessons learnt can be translated into clinical practice. The NHS estimates an economic cost of £600m/year due to non-attendance at clinics. Implementing these strategies would be cost effective and improve patient outcomes. Analysis of a combined dataset of two adherence randomised control trials (NCT01529697 and NCT02307669) to assess the relationship between ACT scores and BMI yielded a significant relationship indicating raised BMI results in lower ACT scores (coefficient -0.134, p 0.001, C.I. -0.214 --0.054). BMI has a significant effect on ACT scores which may lead clinicians to misinterpret asthma control. Clinical trials are increasingly conducted in countries with lower BMIs, therefore trial results may not apply to patient groups in clinical practice elsewhere, whose asthma may be complicated by raised BMI. Aerosolised corticosteroids are commonly used in the treatment and prevention of airway inflammation associated with asthma and other respiratory illnesses. 1 In January 2019 a six-month 0.5 WTE Physiotherapy post was established with the aim of reducing length of stay (LOS) and improving quality of care for respiratory patients. Funding to further progress this post was resumed in January 2020. Data was collected and analysed from January to July 2020. The Physiotherapist screened respiratory patients on their first weekday of admission (n=351). Discharge planning commenced and 215 discharges were accelerated. Patients were discharged to Peamount Healthcare Respiratory Rehabilitation Unit (PHRRU) (n=66) if appropriate. Patients who were discharged home accessed services such as COPD Outreach (n=94), Pulmonary Rehabilitation (n=30) and Oxygen clinic (n=46) if required. The LOS of COPD patients reduced by 1.3 days. There was a 68% increase in transfers to PHRRU and 55% of patients transferred within 24 hours of referral. TUH patients spent a cumulative of 1,491 bed days in PHRRU indicating the number of bed days saved in the acute setting. A patient satisfaction survey was conducted; 108 patients were contacted via phonecall and 49 agreed to participate. The following results were reported: The duraƟon of their inpaƟent stay in TUH was the correct length There was no unnecessary waiƟng or delays during their admission in TUH.

They were informed of their plan of care in TUH.

They understood why they were discharged to PHRRU They were happy to be discharged to PHRRU PaƟent SaƟsfacƟon Survey Results

The Specialist Physiotherapist in Respiratory Pathways improved the efficiency of transfers to PHRRU. This had a positive impact on LOS for COPD patients in TUH. Patients had an early discharge from hospital with appropriate follow up and were satisfied with the service. 

Chronic Obstructive Pulmoonary Disease (COPD) is currently the fourth leading cause of death worldwide. In patients with advanced/GOLD stage D COPD the provision of specialist palliative care is an important component leading to better symptom control and more frequent use of advance care planning. This is a retrospective review of GOLD stage D COPD patients selected from the pulmonary rehabilitation database in St John's Hospital of Limerick. A review of charts and Inpatient Management System (IPMS) was used to record data and determine if palliative care reviewed. 45 patients with COPD were referred for pulmonary rehabilitation in the last two years. Using the combined COPD assessment 23 patients are in group D with palliative care reviewing and following up only 1 (4.3%) of these patients. 5 (22%) of group D patients had a hospital re-admission within 90 days. An integrated approach is required with specialist palliative care and end stage pulmonary disease as this leads to better symptom management and more frequent use of advanced care planning. Although COPD-associated stigma has been explored in small-scale studies, evidence on its causes and implications has not been synthesised. This study aims to explore the phenomenon of stigma in COPD through its causes and impact on pwCOPD. A qualitative meta-synthesis was conducted and reported in line with the Enhancing Nine high-quality studies were included in the synthesis. As per Figure 1 , three themes were identified as causes of COPDrelated stigma and three themes described the impact of stigma on pwCOPD. Stigmatisation of COPD stems from society's negative perceptions of the disease and people with the disease, resulting in adverse psychosocial and lifestyle implications for pwCOPD.

Symptoms of chronic obstructive pulmonary disease (COPD) such as dyspnoea, cough and recurrent chest infections can be non-specific, contributing to diagnostic delays despite patient presentations to healthcare settings 1 . Screening at risk populations results in earlier diagnosis and treatment 2 . Our aim was to target an at risk population, screening them for pulmonary disease. A retrospective chart review of at risk patients, defined as those with respiratory symptoms and >20 pack-year smoking history, referred by Emergency Department (ED) clinicians for Advanced Nurse Practitioner (ANP) assessment was performed. Over 24 months n=61 referrals were received, 54% of which had no previous diagnosis of pulmonary disease. Among those without a prior diagnosis (n=33), n=3 (9%) had no significant disease, n=10 (30%) had normal spirometry but impairment to DLCO attributed to emphysema, n=2 (6%) had very severe COPD, n=2 (6%) severe COPD, n=3 (9%) moderate COPD, n=3 (9%) mild COPD and n=12 (36%) were diagnosed with asthma. Of those with a pre-existing respiratory disease (n=28), n=9 (28%) had a diagnosis change. ANP interventions included initiation of pharmacotherapy and crucial educational/preventative measures such as smoking cessation. ANP-led ED COPD screening targeting symptomatic, at risk individuals has the potential to increase COPD diagnosis and improve patient care. Dyspnoea, Eosinopenia, Consolidation, Academia and Atrial Fibrillation (DECAF) Score is a clinical prediction tool used in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The scores reflect in-hospital mortality risk. Scores of 0-1; low risk, 2; intermediate risk and 3-6; high risk. A prolonged hospital stay during an episode of AECOPD increases the risk of associated medical complications. Using the DECAF can guide appropriate early discharge from hospital to community follow up. Hospital admissions for exacerbation of COPD are a major cost to health services. Reducing length of stay (LOS) will reduce cost. The European COPD audit (ERJ,2013) calculated the mean LOS at 8.7days. The National Institute for Health and Clinical excellence (NICE) guidelines suggest that early discharge to appropriate community care can reduce the cost burden. A retrospective study of patients admitted with AECOPD from June to December 2019 were examined. The DECAF score and LOS was calculated on each. A prolonged LOS was defined as greater than 5 days. A total of 47 patients were included in this study. The average LOS calculated for this group was 5.92 days. Thirty nine of this group had a DECAF score of 0-1. The average LOS for low risk patients was 5.439 days. 38.4% scoring a DECAF of 0-1 showed a prolonged length of hospital stay. More than one third of patients could have been discharged earlier if there was suitable services in our community. COPD has a significant impact on respiratory morbidity and mortality resulting in frequent exacerbations that often require hospital admissions. Studies have proven that self-management programmes among COPD patients result in improved self -management decisions leading to an improved quality of life. The use of a smartphone app has the potential to support the delivery of a self-management programme, thereby improving the quality of life in patients with COPD. To evaluate the literature pertaining the use of a smartphone app in supporting a self-management programme among COPD patients. Systematic searches of bibliographic databases such as MEDLINE, CINAHL, AMED, CENTRAL and PubMed pertaining to smartphone apps relating to self-management programmes used in COPD patients. Initial search generated 1709 articles, after screening of articles and reference lists, ten studies met the inclusion criteria for this review. A self-management programme via a smartphone app is feasible among COPD patients. Moreover, there should be a focus on simplicity of structure and ease of use for data capture. As limited research exists, further randomised control trials are required. Pulmonary Rehabilitation (PR) as we know it ended in UHL on March 6 th 2020. Uncertainty and indecision followed-lots of phone reviews and reassurance. UL MSc physiotherapy students came onboard to lend a hand. Together we endeavoured to help our current participants to finish out the course-both online and over the phone. With a guidance document from the National Clinical Care Program in COPD & Asthma on Virtual PR released in April we set about recruiting participants for the first Virtual Pulmonary Rehabilitation Program (VPR) in the Mid West. 45% of those surveyed off the waiting list were interested in participating and felt they would have the relevant technology to participate. The Attend Anywhere platform was the chosen interface for virtual clinician-patient contact in UHL. 10 participants were assessed for the program. Assessment includedreview of diagnosis via medical chart, PFTs, imaging and bloods, COPD Assessment Test, Hospital Anxiety Depression Scale, Modified Falls Efficacy Scale and 1 minute Sit to Stand. 9 completed the 8 week program-one drop out due to technological difficulties. Low uptake rates, low attendance rates and high drop out rates are common problems for PR programs. We finished our program with a 75% attendance and a 90% pass ratewith the traditional PR model we would have had up to 40% drop out rate. Both subjective and objectives outcomes measures were very positive. The group have continued to meet to exercise via another virtual platform since completing the program. Long term compliance with the lifestyle modification from VPR will be interesting to follow up. The group that engaged in the program and had the relevant technology and skill set to utilise the technology showed significant benefits-in keeping with face to face pulmonary rehabilitation. The fact that an independent exercise class has continued may suggest a more sustained benefit. COPD Outreach (COPDOR) provides early supported discharge to hospital presenting patients with an acute exacerbation of COPD. The national target is to accept 20% of all COPD patients and to reduce overall hospital length of stay (LOS). The purpose of this report was to analyse data from 2016-2020 using Microsoft Excel to review 1) CAT scores at Week 1 and Week 6 and 2) the percentage of COPD patients accepted by COPDOR and their average LOS. Data was collated from the COPD Outreach and TUH HIPE databases to analyse this activity. CAT scores reported at week 1 showed no statistical difference from 2016-2020. The average percentage improvement from week 1 to week 6 was 36%, and was consistent from 2016-2020. The target of accepting 20% of all COPD patients was achieved only in 2019 (21%) and will in 2020 (42% at end of August). However, these figures may be disingenuous due to substantially lower admissions rates secondary to COVID-19. Average LOS (Table 1) is at its lowest this year for patients accepted on the COPDOR Programme potentially due to a notable shift towards earlier supported discharge pathways (LOS 0-3 days) and away from supported discharges (LOS 4+ days). Six lobe Bronchoalveolar lavage (BAL) during bronchoscopy in children has been reported to be safe and confer a higher microbiological yield. Regional variability in CF lung disease is well described clinically but the etiology remains incompletely understood. The aim of our study is to assess the safety of a standardised six lobe BAL collection technique using 2x1ml/kg/lobe and to evaluate the factors contributing to regional variability in infection and inflammation. Samples were processed into individual lobar, two (RML & lingula) and six lobe pooled aliquots. In this interim analysis, IL-8 was measured in BAL supernatant using a commercially available kit. Samples from Five subjects were included with mean age 3.4yrs (range 2-5yrs Ireland has participated in seven data collection waves of ESPAD (European Schools Project for Alcohol and Other Drugs) between 1995 and 2019, during which time more than 500,000 students have completed questionnaires on substance use, including cigarettes.

In 2019, some 100,000 students participated in ESPAD. In Ireland, 1967 students, born in 2003, were surveyed from a stratified random sample of 50 Irish schools. We compared prevalence and gender differences in the Irish and European samples at different time points from 1995 to 2019. In Ireland and across Europe, total prevalence of 30-day smoking decreased significantly between 1995 and 2019. Ireland's decrease (from 41% to 14%) was more dramatic than the European average (32% to 20%). Ireland's current prevalence is lower than the European average. However, while there was a decline of 5% in the European average between 2015 and 2019, Ireland's decreasing trend reversed, accounted for by an increase in male smoking from 13% to 14%. In Ireland, smoking prevalence in 15-16-year-olds has increased for the first time in 25 years. Further focused action is urgently needed to achieve a prevalence of 5% by 2025. Conflicts of interest: None Descriptive statistical techniques were used to estimate changes in prevalence, reasons for trying e-cigarettes, and relationship with tobacco at first use. Prevalence of ever-use increased from 23% in 2014 to 39% in 2019, representing a rapid increase, particularly since 2016. Curiosity (66%) and friends (29%) are now the two main reasons adolescents use e-cigarettes. Those saying they had never used tobacco when they first tried e-cigarettes increased from 32% in 2015 to 68% in 2019. E-cigarette use has risen rapidly among adolescents in Ireland since 2014. E-cigarettes are not used by adolescents for smoking cessation. The majority of adolescents who use e-cigarettes were not smokers when they started using e-cigarettes, pointing to a worrying new route into nicotine addiction. Current tobacco control regulations for young people should be extended to include e-cigarettes. 

Use of non0-invasive ventilation for patients with Covid-10; a cause for concern?

Infectious Diseases, Beaumont Hospital

Coagulopathy and antiphospholipid antibodies in patients with Covid-19

Clinical course and risk factors for mortality of adult inpatients with Covid-19 in Wuhan, China: a retrospective cohort study

Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19

ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study

Efficacy and safety of the elexacaftor plus tezacaftor plus ivacaftor combination regimen in people with cystic fibrosis homozygous for the F508del mutation: a double-blind, randomised, phase 3 trial

Elexacaftor-Tezacaftor-Ivacaftor for Cystic Fibrosis with a Single Phe508del Allele

Molecular evidence for the role of mycobacteria in sarcoidosis: a meta-analysis

Etiologic aspect of sarcoidosis as an allergic endogenous infection caused by Propionibacterium acnes

Lymphangioleiomyomatosis: calling it what it is: a low-grade, destructive, metastasizing neoplasm

2.5. Defining the "F" in Fibroblast: a definitive identification of mesenchymal populations in the healthy and fibrotic lung References 1

James's Hospital, Dublin 8. 5. Department of Oncology, HOPE Directorate

SCTS Current Recommendations Regarding Screening for COVID-19 in Patients undergoing Cardiothoracic Surgery

Recommendations-Regarding-Screening-for-COVID-19-in-Patients-Undergoing-Cardiothoracic-Surgery-22nd-April-2020.pdf References 1. 2002 National Kidney Foundation clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification

Optimizing CT Pulmonary Angiogram Utilization in a Community Emergency Department: A Pre-and Postintervention Study

Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism-revisited: A systematic review and meta-analysisEmergency

References 1. Electronic cigarette use among Irish youth: A cross sectional study of prevalence and associated factors

Binding and activity of the prostacyclin receptor (IP) agonists, treprostinil and iloprost, at human prostanoid receptors: treprostinil is a potent DP1 and EP2 agonist

Human cholecystitis is associated with increased gallbladder prostaglandin I2 and prostaglandin E2 synthesis

Incorporating Virtual Telehealth into the Oxygen Clinic in Tallaght University Hospital (TUH)

The Impact of Clinical Decision Rules on Computed Tomography Use and Yield for Pulmonary Embolism: A Systematic Review and Meta-analysis

Performance of algorithms and pre-test probability scores is often overlooked in the diagnosis of pulmonary embolism

Irish Guidelines on the Administration of Oxygen Therapy in the Acute Clinical Setting in Adults

Oxygen Therapy in Ireland: A Nationwide Review of Delivery, Monitoring and Cost Implications

Does Wells score documentation really prevent excessive CTPA requests in a teaching hospital? A retrospective study in 800 patients

Sniff nasal inspiratory pressure as a marker of respiratory function in motor neuron disease

Assessing Inspiratory Muscle Strength for Early Detection of Respiratory Failure in Motor Neuron Disease: Should We Use MIP, SNIP, or Both?

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British Thoracic Society Guidance on Respiratory Follow Up of Patients with a Clinico-Radiological Diagnosis

Improving early detection of chronic obstructive pulmonary disease

Audit of the appropriate prescribing of Low Molecular Weight Heparin in a busy Regional Hospital A Rafi 1

Profile of Patients Who Drop out of a Pulmonary Rehabilitation Program

What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review

The British Thoracic Society guideline on pulmonary rehabilitation in adults: your opinion is noted

Explaining adherence to supplemental oxygen therapy

Compliance with LTOT and consumption of mobile oxygen

Implement and Evaluate an Integrated Care Pathway for Patients Presenting with Pneumothorax Ben Shanahan 1

References 1. ARTP (association for respiratory technology and physiology): standards of care in sleep apnoea

3.1.5. Pilot study to assess the accuracy of Positive Airway Pressure (PAP) derived Apnoea-Hypopnoea Index (AHI) by using an Independent Novel PAP home monitoring device

Department of Health. Management of an Acute Asthma Attack in Adults (NCEC National Clinical Guideline No. 14). Dublin: Department of Health

Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report

Low uptake of palliative care for COPD patients within primary care in the UK

End of life strategies among patients with advanced chronic obstructive pulmonary disease (COPD)

Aspirin-Exacerbated Respiratory Disease -New Prime Suspects

Diagnosis and management of NSAID-Exacerbated Respiratory Disease (N-ERD)-a EAACI position paper

NSAID exacerbated respiratory disease; one day protocol for challenging and desensitising patients using 45 minute intervals

Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis

Outcomes of the short Synacthen test: what is the role of the 60 min sample in clinical practice

Asthma inhalers and devices Poster 2020: "which one is it?" Carrig C. 1 , Mc Donald M. 1 , Devitt M. 1

Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders

Anaesthetic and respiratory equipment -Nebulizing systems and components 4.22. A Review of the Use of Omalizumab in a

International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

Shahzad Q 1 , Helly F 1

Department of Respiratory Medicine St. Luke's General Hospital

Meta-analysis of asthmarelated hospitalization in mepolizumab studies of severe eosinophilic asthma

An audit of anti-IL5 therapy in a severe asthma clinic at Mercy University Hospital (MUH), Cork

Mepolizumab Treatment in Patients with Severe Eosinophilic Asthma

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease

Using thematic analysis in psychology

Dublin-4. References 1. Department of Health -Management of an Acute Asthma Attack in adults, National Clinical Guideline No. 14

Identifying undiagnosed COPD through searches of UK routine primarycare databases

Screening for COPD: the gap between logic and evidence

Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Pulmonary Disease

COPD outreach programme model of care, national COPD quality in clinical care programme; 2011. 4.35. An overview of the establishment and implementation of a Virtual Pulmonary Rehabilitation Programme for COPD and Asthma patients in Cork University during a global pandemic. References 1. Global Initiative for Chronic Obstructive Lung Disease (2019) Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease

British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE

Dublin 9. 1 Department of Biochemistry, Beaumont Hospital, Dublin 9. 2 Department of Biochemistry and Clinical Genetics

Irish Centre for Genetic Lung Disease, RCSI Education and Research Centre

Guidelines advocate screening all COPD, poorly-controlled asthma, and cryptogenic liver disease patients, as well as first degree relatives of known AATD patients. The most common harmful mutation is Z (1 in 25 Irish people are carriers) which leads to a severe plasma deficiency if AAT. 1 in 10 Irish individuals carry the less harmful S mutation (Glu264Val, rs17580), one of the highest allele frequencies in Europe. However, the true clinical significance of the S mutation remains poorly understood (1)

The prevalence of alpha-1 antitrypsin deficiency in Ireland

Discipline of Physiotherapy, School of Primary and Allied Health Care

Airway clearance techpractice

Airway clearance techniques for

Hospitalized exacerbations of COPD: risk factors and outcomes in the ECLIPSE cohort

Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation: A Randomized Clinical Trial

Kaplan-Meier survivor funcƟon, straƟfied by use of non-invasive venƟlaƟon (NIV) at home prior to admission. Blue line represents those using NIV at home and red line those that were not. References 1. Electronic cigarette use among Irish youth: A cross sectional study of prevalence and associated factors

Aerosol Delivery Characterisation during Simulated Mechanical Ventilation of a Neonate L

Aerosol therapy is commonly prescribed during mechanical ventilation within the neonatal intensive care setting. The objective of this study was to characterise aerosol delivery using a vibrating mesh nebuliser (VMN) and jet nebuliser (JN) at two circuit positions during simulated neonatal mechanical ventilation in an infant incubator. A VMN (Aerogen Solo, Aerogen, Ireland) and JN (Cirrus™2, Intersurgical, UK) were placed at the dry side and 30 cm before the wye within a humidified circuit

Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders

Dexamethasone for acute asthma exacerbations and viral induced wheeze: quality improvement in a Paediatric Emergency Department Ruddell

Mulhouse Road, Belfast, BT12 6DP, Northern Ireland 2 Children's Emergency Department, Royal Belfast Hospital for Sick Children, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

To assess the accuracy of the AHI reported by multiple commercially available PAP devices using the Dynomed device. Both AHI values from PAP and Dynomed were compared to Physiologist scored AHI from a simultaneously recorded limited sleep study (LSS).Asthma is a chronic inflammatory condition resulting in episodes of reversible airway obstruction. Severe asthma accounts for 10% of all disease (1) , and poses a significant therapeutic challenge. In recent years, a number of biological therapies have been approved for treatment of steroid refractory asthma. We reviewed the use of Omalizumab in patients commenced on the drug over a ten year period using electronic patient records. We compared pre and post treatment spirometry, frequency of exacerbations per year and mean daily steroid intake. We identified 14 patients (50% male; mean age 59.07 years) commenced on Omalizumab during this period. Mean daily steroid use decreased from 10mg Prednisolone per day to 5mg per day while on Omalizumab. Most patients (86%) had reduced rates of exacerbations while on the drug. 75% of patients also had improved spirometry results on treatment, with an average improvement of 10% in forced expiratory volume. This review highlights the beneficial effects of Omalizumab in a small patient population in a tertiary referral centre. A further review of patients who failed to improve on Omalizumab could be worthwhile to elucidate any common patient characteristics that might indicate poor response to therapy.Mepolizumab (Nucala®), a monoclonal antibody specific for IL-5, has been shown to reduce hospitilisation rate's for those with severe eosinophilic asthma by half when compared to placebo 1 . At St. Luke's General Hospital, Co. Kilkenny (SLK) a cohort of patients (n=8) began Mepolizumab treatment for severe eosinophilic asthma. Here a retrospective study to assess efficacy of Mepolizumab in this cohort is presented. On average patients have received of 16.50 months of treatment, with 50% (n=4) completing >18months of treatment. Post induction, the average steroid dose required has reduced by 73.77% from 22.5mg/day to 5 A direct access respiratory advanced nurse practitioner (ANP) service was developed in 2018 to support St. Michael's Hospital Emergency Department (ED) by providing evidenced-based care and timely access to patients presenting with symptoms related to asthma and/or chronic obstructive pulmonary disease (COPD). A retrospective review of 50 care episodes between October-December 2019 was performed to evaluate interventions provided by ANPs related to care delivery and patient follow-up, with questionnaires prepared using national guidelines for asthma 1 and COPD management 2 . All patients received standardised, evidence-based assessment and treatment. Additional ANP initiated interventions included: respiratory inhaler management (58%), treatment of upper respiratory (36%) and gastrointestinal (6%) symptoms and smoking cessation (36%). Non-pharmacological management included: initiation of high flow oxygen (4%) and provision of health-related education e.g. trigger avoidance, peak flow diary and vaccinations. Disposition decisions included: medical referral (34%), ED review for non-respiratory symptoms (10%) and discharge (56%). Discharge follow-up included: COPD outreach service (48%), ANP-led review (16%), respiratory clinic (34%) and GP (32%). Consultation referrals included cardiology, palliative care, orthopaedics and physiotherapy. A direct access ANP service in the ED for asthma and COPD assists evidence-based evaluation and treatment, supplements standard care by promoting patient-centred management and links patients to specialist services.All authors contributed equally to this work. In February 2020 the Respiratory Clinical nurse specialist (CNSp) service undertook a four week audit of COPD patients. Included were patients from both the inpatient and outpatient setting as well as nurse-led clinics. The aim of the audit was to assess if the patient's inhaled therapy was in line with the recommendations as per GOLD Guidelines and the ABCD assessment tool (GOLD 2020). Respiratory nurse specialists follow guidelines in order to ensure patients receive the most appropriate therapy for their disease stage. We wished to investigate, by means of audit, that we were adhering to these guidelines and that the appropriate therapy was prescribed.A number of reasons for changing inhaled therapy were identified. These included inappropriate therapy, increased exacerbation rates, inhaler technique optimisation and up-titration of treatment. Additional reasons for changes to patients inhaled therapies were unintentional non-adherence and prescribing errors. It was noted during the audit that 65% of the patients seen required a change of therapy, highlighting the importance of the role of the respiratory CNSp in the optimisation of inhaled therapy for COPD patients. Unfortunately due to the Covid-19 pandemic we were obliged to cut the audit short. We intend to revisit this audit when feasible.A virtual pulmonary rehabilitation (VPR) programme was established in CUH for patients on the waiting list for conventional PR. 13 patients were contacted, 6 accepted enrolment and 4 completed the first VPR programme which comprised of a 7 week group exercise and education programme using the WebEx Platform. 1min STS test was used to assess functional exercise capacity. The HADS, CAT and MMRC were completed pre and post programme. Results were analysed using a t-test. Mean age of participants was 68 years. (75% COPD, 25% ACOS). Mean improvement in 1min STS = 8.75 repetitions (P 0.067). Each patient improved by >7 reps with an improvement ≥3 showing clinical significance. There were non significant improvements in CAT. In this small pilot study, a VPR programme has shown to be an effective way of improving exercise capacity at a time when it is not feasible to run conventional PR programmes. This study looked at the satisfaction of patients accepted onto the COPD Outreach programme in TUH during the nationwide lockdown period (March to May 2020) as compared to patients accepted pre COVID19. The COVID19 pandemic has caused major disruption across the health service in Ireland -COPD Outreach in TUH included. The usual programme of home visits to patients following discharge with an acute exacerbation of COPD was interrupted. As a result, all patient contact during the lockdown period was completed over the phone. This was not ideal and it was decided to assess patients' satisfaction with the quality of the care received during this period. Satisfaction questionnaires are routinely posted out to patients following their discharge from COPD Outreach. Eighteen patients were accepted onto the COPD Outreach programme during the lockdown period. These received telecontact questionnaires by the unbiased hospital administration team. Eighteen questionnaires from 2019 were randomly selected and the responses were compared to those from the lockdown period. Both groups were "very satisfied" with the overall care and service they received from the COPD Outreach team. This is very positive as it may allow the service to expand to those outside our traditional catchment area in the future. Pulmonary Rehabilitation (PR) is recommended for patients with chronic obstructive pulmonary disease (COPD) to improve quality of life, and to reduce exacerbation frequency and hospitalisations 1,2 . However, the benefits of PR appear to decline over time if participants do not continue maintenance exercise 2 . As a result, PR participants should be encouraged to continue exercising, including through community exercise groups, to maintain benefits.This study aimed to ascertain if patients who completed PR remained compliant with exercise afterwards, and whether they joined a community COPD exercise group. Patients who completed PR including a post-PR assessment between January 2019-January 2020 (n=83) were contacted by telephone and responded to a questionnaire. 77% (n=64) of patients completed the telephone questionnaire. Of these, 27 (42%) were female and 37 (58%) male, with a mean age of 70±11 years. The majority (80%, n=51) had a diagnosis of COPD. Overall 81% (n=52) of patients reported continuing to exercise after PR completion with no significant difference in age or sex between groups. Of these, only 29% (n=15) reported joining a community COPD exercise group. These data suggest that most patients continue to exercise upon completion of PR but do so independently without joining community COPD exercise groups.In light of the COVID19 pandemic and need for social distancing, many out-patient services have opted for phone call consultation or virtual clinic (VC). We aimed to establish if VC is a viable alternative to face-to-face clinic (F2FC) in a respiratory department. One-Hundred participants were asked to fill out patient satisfaction questionnaires via phone call. Eighteen physicians within the department were also asked to fill out questionnaires. The majority of patients (94%) were satisfied with VC and agreed that VC was convenient (n=90), information was relayed clearly (n=96) and covered everything that patients wanted to discuss (n=92). VC was deemed comparable to F2FC by 83 patients. However, 44 (44%) patients preferred F2FC in the future. From the physician perspective, 10 (56%) were satisfied with VC and 8 (45%) felt that it was comparable to F2FC. Interestingly, 11 (61%) physicians had no specific clinic preferences. Through Chi-square test, we found significant difference where patients had higher mean score as compared to physicians for all studied variables. Virtual clinics, by phone call, is a feasible medium to continue running a respiratory out patient service while adhering to social distancing with good patient satisfaction. In addition we have identified ways to improve this service. During the COVID-19 pandemic virtual clinics (VC) were utilised in many outpatient settings in place of standard outpatient visits, with some centres continuing this following the lockdown period. This study aimed to ascertain whether, if given the option, existing respiratory nurse-led clinic (NLC) patients with chronic obstructive pulmonary disease (COPD) and/or asthma, would prefer a VC over a standard outpatient clinic visit. 35 current respiratory NLC patients were surveyed by phone regarding their preferences related to virtual vs standard outpatient clinics, and digital literacy and access. The mean age of participants was 56 years, 27 (77%) were female and 8 (23%) were male. 18 (51%) had COPD, 12 (34%) had asthma and 5 (15%) had asthma-COPD overlap syndrome. The majority of patients (n=20, 57%) preferred to attend a standard outpatient clinic. Of the 15 (43%) who preferred to be reviewed virtually, only 3 (20%) would utilise this option if they felt their condition was unstable, with the remaining 12 (80%), preferring to attend an outpatient clinic if unwell. This study demonstrates that, while VC have a role, particularly during a lockdown period, the majority of patients within this service would rather attend the outpatient clinic as normal, particularly when unwell. Monoclonal antibody against interleukin-5, is approved as an add-on treatment for adult patients with severe eosinophilic asthma (SEA). Current literature suggests immunosuppressive conditions and medications predispose to an increased risk of opportunistic infections. We aimed to evaluate the incidence of opportunistic infections on SEA patients receiving anti IL-5 therapy. A retrospective telephonic survey was conducted on all SEA patients treated with Reslizumab, Mepolizumab and Benralizumab in Tallaght and Peamount Hospital. Key parameters assessed included annual exacerbation rate, corticosteroid therapy, incidence of opportunistic infection; namely varicella and herpes zoster, parasitic and COVID-19 infections as well as vaccination history. Thirty-six patients (mean age: 57.3 years, 56% female) were included. Mean duration of therapy was 23.9 months, and 50% of patients were on oral corticosteroids. The mean annual exacerbation rate was 2.7. Twenty-four patients reported prior varicella infection or vaccination, and none received herpes zoster vaccination. Two patients (5%) receiving Mepolizumab experienced ontreatment herpes zoster infection, while there was no parasitic or COVID-19 infections reported.In conclusion, SEA patients on anti IL-5 therapy do not seem to present a higher risk of opportunistic infections and this result appears similar to clinical trials. The Fractional Exhaled Nitric Oxide (FENO) is a non-invasive tool of measuring eosinophilic airway inflammation and assessing airways disease. In sports, the presence of asthma and related diseases is frequent, therefore FENO may be a helpful marker evaluating those cases. We performed a cross-sectional study aiming to evaluate the FENO levels in Elite Gaelic Athletes and its correlation with spirometry and presence of airway symptoms (upper or lower). The study group consisted of 43 male athletes aged 21 to 32. On December 2019, we performed spirometry and FENO measurements on all subjects and collected their background clinical history and respiratory symptoms. A weak negative correlation was found between FENO and Forced Expiratory Volume (FEV1) values (r=-0,2639; p=0,087). We verified that the presence of airway symptoms in athletes with history of asthma was 67% while without was 35%, however not significantly different (p=0,133). Significant difference was found in values for FENO between 25 athletes without and 18 with airway symptoms (p=0,0348). Analysing the type of symptoms, mean FENO was higher in upper airway symptoms (mean=66,40) compared to lower airway symptoms (mean=50,63), even though not significantly different (p=0,4940). Thus FENO seems to correlate with airway symptoms but not with a drop in FEV1.The purpose of this study was to explore current practices of physiotherapists' use of airway clearance techniques (ACTs) for patients experiencing exacerbations of chronic obstructive pulmonary disease (ECOPD) in the Republic of Ireland (ROI). A cross-sectional online survey using multiple-choice questions and Likert scales was distributed to 202 participants directly via email and via the Irish Society of Chartered Physiotherapists (ISCP). Seventy of 202 responses (35%) were received. Physiotherapists in ROI use ACTs physical exercise (PE) (n=93%) and breathing exercises (n=90%) most frequently for ECOPD. Sputum management (n=94%) is the most commonly reported indicator for use of ACTs. The majority of physiotherapists (n=60%) reported being unsure of the literature or finding the literature conflicting/non-existent in relation to ACTs. Despite lack of evidence to support the use of ACTs, physiotherapists continue to use them in their management of ECOPD, consistent with similar international findings (1,2). In order to reduce the disease burden of COPD and improve patients' quality of life, future studies are required to determine the efficacy of PE and the combination of PE with other ACTs. The clear translation of research findings to physiotherapists must be prioritised in order to disseminate clinically useful strategies for the management of ECOPD. 

Dry powder inhalers (DPIs) are an effective method of medication delivery, however, if a patient cannot provide sufficient inspiratory flow, inadequate medication reaches distal airways. We describe the development of a cost-effective acoustic device that can accurately determine whether a patient is suitable for a DPI. A small, T-shaped, hand-held acoustic device with a mouthpiece, inflow aperture and a resonance chamber was designed. Upon inhalation through the mouthpiece, air flows in through the inflow aperture and is directed into the resonance chamber by a labium. The device was specially designed to favour different ratios of fundamental and harmonic acoustic resonance at different airflows. The device's acoustic transition point, the inspiratory flow rate above which the device acoustics change to mark sufficient airflow, was tailored to account for the resistance and required airflow of common DPIs. A simple audio analysis program that can be employed on smartphones was used to analyse acoustics via a Fast Fourier Transform. The current device version detects sufficient airflow with 95.2% sensitivity and 100% specificity. In conclusion, we developed a small, extremely cheap acoustic device suitable for biodegradable materials (PLA) that determines DPI suitability, and therefore whether an aerosolised or nebulised medication is more appropriate. Chronic Obstructive Lung Disease (COPD) remains a major cause of morbidity and mortality across the world. (1) We evaluated survival at 1,2 and 5 years in a cohort of patients with COPD requiring acute inpatient non-invasive ventilation. We analysed prognostic indices to evaluate if they were predictive of mortality. We performed a retrospective chart review of all patients who were admitted to St. James's Hospital respiratory ward with acute hypercarbic respiratory failure who required non-invasive ventilation (NIV) over a 12 month period and followed their outcomes over 5 years. 99 patients were identified over a 12 month period from January to December 2011. Survival at 1, 2 and 5 years was 65% (n= 64), 42% (n=42) and 25% (n=25) respectively. Increasing age (p<0.001) and a lower serum albumin (p <0.005) were predictive of worse survival. There was a trend towards improved five year survival in the group who had preexisting home NIV prior to admission compared to no NIV therapy at home but this did not reach statistical significance (Figure 1 , p value< 0.088). This study highlights the high mortality in patients with COPD admitted with hypercarbic respiratory failure requiring NIV. Home NIV may be protective however this did not reach statistical significance. This adds to our knowledge of the protective benefits already known in relation to home NIV in COPD. ( Children with Down syndrome (DS) have increased prevalence of obstructive sleep apnoea (OSA), for which non-invasive ventilation (NIV) is a cornerstone of management. Compliance has previously been described as a major issue in the therapeutic efficacy of NIV within the DS population. This study aimed to measure adherence and delivery of NIV within a paediatric DS cohort. This retrospective cohort study involved 106 children with confirmed OSA and home NIV with downloadable data. Children were divided into DS (n=44) and non-DS cohorts (n=62). Adherence and clinical outcomes, such as apnoea-hypopnoea index (AHI), delivery and system leakage were recorded and compared between DS and non-DS cohorts and within the DS cohort based on age and surgical history. Significantly greater NIV usage, in the form of percentage days used, was observed in the DS cohort relative to non-DS counterparts (p=0.031). However, children with DS displayed significantly greater system leakage (p=0.022) and increased AHI (p=0.0493). Surprisingly, those with DS with prior cardiothoracic surgery showed significantly reduced compliance. These data confirm that satisfactory NIV adherence is achievable in children with DS. However, we have identified excessive system leak at the machine-patient interface as a factor, which could undermine NIV efficacy in children with DS. Aerosolised corticosteroids are commonly used in the treatment and prevention of airway inflammation associated with asthma and other respiratory illnesses. 1 The aim of this study was to assess aerosol delivery performance of Budesonide during simulated adult and paediatric spontaneous breathing. A standard 2 mL dose of Budesonide (Pulmicort 0.5 mg/2 mL, Astra Zeneca, UK) was aerosolised using the Aerogen Solo (Aerogen, Ireland) in combination with the Aerogen Ultra aerosol chamber and facemask, with 2 litres per minute supplemental gas flow. A breathing simulator (Copley Scientific, UK) in combination with appropriate head models was used to generate both adult (Vt 500mL, 15 BPM, I:E 1:1) and paediatric (Vt 155 mL, 25 BPM, I:E I:2) breaths as per International Standard ISO27427. 2 The mass of drug delivered to the level of the trachea was determined using UV spectrophotometry (241 nm). Five replicates were performed for each test. Following test, the recorded tracheal doses were adult (23.36 ± 1.35 %), and paediatric (15.14 ± 1.15 %). This study confirms that high levels of Budesonide can be delivered using a vibrating mesh nebuliser. This information should inform clinicians in their approach to clinical aerosol therapy.

All authors are employees of Aerogen.