ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE

Irish Thoracic Society Annual Scientific Meeting 2014 7th–8th November 2014 Radisson Blu Hotel, Galway

Irish Journal of Medical Science Volume 183 Supplement 11 DOI 10.1007/s11845-014-1196-y

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The Irish Thoracic Society thanks the following companies for their generous support, in the form of unrestricted educational grants, of the 2014 Annual Scientific Meeting: The Irish Thoracic Society Guest Lecture I and Oral and Poster Awards Supported by an unrestricted educational grant from Boehringer Ingelheim Ireland

The Irish Thoracic Society Debate on Lung Cancer Screening Supported by an unrestricted educational grant from Boston Scientific

The Irish Thoracic Society Guest Lecture II Supported by an unrestricted educational grant from Vertex

The Irish Thoracic Society SpR Study Day and Case Study Forum Supported by an unrestricted educational grant from Astra Zeneca

The Irish Thoracic Society Update Lecture Supported by an unrestricted educational grant from Intermune UK and Ireland

Irish Thoracic Society Meeting Programme Supported by an unrestricted educational grant from Pfizer

Irish Thoracic Society Meeting Delegate Bag Supported by an unrestricted educational grant from Baywater Healthcare

Irish Thoracic Society Drinks Reception Supported by BOC Healthcare

The ANAIL Forum Supported by an unrestricted educational grant from Mundipharma Pharmaceuticals

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Exhibitors at the Irish Thoracic Society Annual Scientific Meeting 2014

Pharmaceutical and Medical Device Suppliers InterMune UK and Ireland Actelion Pharmaceuticals UK Ltd A Menarini Pharmaceuticals Ireland Astra Zeneca Bayer HealthCare Baywater Healthcare BOC Healthcare Boehringer Ingelheim Boston Scientific Cardiac Services Group Direct Medical Ltd Eurosurgical Ltd Forest Laboratories UK Ltd GSK Home Healthcare Ltd

Meda Health Sales Ireland Ltd Medicare Health and Living Ltd Mundipharma Pharmaceuticals Ltd Novartis Ireland Ltd Orion Pharma (Ireland) Ltd Pfizer Healthcare Ireland (Anti-infectives) Pfizer Healthcare Ireland (Champix) Pharmaxis Pharmaceuticals Ltd ResMed/PEI RespiCare Ltd Sanofi Sword Medical Ltd Teva Pharmaceuticals Ireland Vertex Pharmaceuticals (UK) Ltd

Patient Charities The Alpha One Foundation The Asthma Society of Ireland COPD Support Ireland Cystic Fibrosis Ireland The Irish Cancer Society The Irish Hospice Foundation The Irish Lung Fibrosis Association The Irish Sarcoidosis Support Network The Irish Sleep Apnoea Trust

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Disclosure Statement The operational costs of the Irish Thoracic Society Annual Scientific Meeting 2014 are funded with the support of a number of commercial bodies through unrestricted educational grants. These are listed overleaf.

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Welcome from the Local Organisers It is our great pleasure to welcome you to Galway, host to the 2014 Irish Thoracic Society Annual Scientific Meeting. Following from a hugely successful meeting in Derry in 2013, we are delighted to see the meeting’s return to the City of the Tribes and have put together a programme that reflects the best of respiratory medicine and healthcare and offers ‘state of the art’ education on a range of topics. Thank you to all those who submitted abstracts and case studies this year—almost 200 in all—reflecting the high quality and innovative work taking place in clinical and research centres throughout the island. We would also like to thank the abstract review committee and judges for their time and expertise in what is never an easy task due to the increasingly high standard of submissions received. The meeting will feature a combination of clinical and molecular research including: a presentation on use of patient data in clinical decisions by Prof Martin Tobin, Loyola University of Chicago; an update on the treatment of IPF by Prof Jim Egan; a pro-con debate on lung cancer screening featuring international experts Prof James Jett from National Jewish Health in Denver and Dr Cyrus Daneshvar, Plymouth University Hospitals, and a presentation on information technology and healthcare by Dr Ronan Kavanagh. Welcome also to the patient and professional organisations represented. Networking and sharing information on the wealth of activities taking place across the respiratory healthcare community has become an integral part of the meeting. Finally we would like to extend a particular welcome to the exhibitors and sponsors of this year’s meeting. We are very grateful for their continued support. Yours sincerely,

Prof Anthony O’Regan

Dr Robert Rutherford Local Organisers, ITS Annual Scientific Meeting 2014

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President’s Welcome On behalf of the Irish Thoracic Society, I am delighted to welcome you to the ITS Annual Scientific Meeting 2014. I would like to take this opportunity to update you on the work of the Society over the past 12 months particularly in the areas of education, research, advocacy and public health. Advocacy and Public Health The ITS continues to play a central role in the work of the Irish Lung Health Alliance in raising awareness of lung disease amongst policy makers and the public. A series of public lectures, delivered by ITS members, patient representatives, and guest speakers took place throughout the country in late 2013. These were very well received and generated broad media coverage. Thanks to all those involved in making the campaign a success and to Boehringer Ingelheim Ireland for their support. To coincide with the ERS ‘Healthy Lungs for Life’ campaign in September 2014, the Alliance organised a nationwide awareness and public health campaign in conjunction with the Irish Institute of Clinical Measurement Science (IICMS) Faculty of Respiratory, Glasgow Science Centre and supported by GSK. The initiative, which was launched by Minister for Health, Mr Leo Varadkar, saw a Lung Health Roadshow incorporating the BodyWorks On Tour Exhibition and Free Lung Testing visit a number of key locations throughout Ireland, including Portlaoise, Ireland’s Healthy Town 2014. 2014 saw the introduction and approval of the Standardised Packaging of Tobacco Legislation—a vital step in protecting future generations of Irish children against tobacco related illness. The ITS actively supported this measure through our work as part of the Health Charities Coalition and our attendance at the Committee Hearings of the Joint Oireachtas Committee for Health and Children. We were very pleased to play an advocacy role in progressing this essential legislation. Also on the theme of tobacco and public health we are planning a Symposium on Smoking and Pregnancy to take place on the 18th November in conjunction with the TobaccoFree Research Institute (TRI) and the Royal College of Physicians of Ireland (RCPI). This will be based on research carried out by the TRI and presented at this meeting in previous years which shows the high prevalence of smoking in pregnancy, the health implication for babies born to mothers who smoke and the lack of smoking cessation services for pregnant women. This poses a serious public health challenge which we feel needs to be highlighted. Research Thanks to the support of Allen and Hanburys, Boehringer Ingelheim and Novartis, through unrestricted educational grants, the Irish Thoracic Society has been able to continue offering much needed funding for research in respiratory medicine. We are pleased to report that we have once again been successful in securing joint funding through the MRCG HRB Joint Funding Scheme 2014. The successful grant is titled ‘Investigating the impact of bile aspiration on chronic respiratory disease: Chronic infection—Bile Paradigm led by Prof Fergal O’Gara, UCC with coapplicants Dr Muireann Ni Chroinin and Dr David Mullane. This was the result of a highly competitive and rigorous grant review process. Thanks to the support of our partners and participation in the joint funding scheme we have been able to offer grants for research in respiratory medicine to the total value of €320,000.00 over the past 3 years. Education The ITS Spring Meeting 2014 took place in Kinsale in April. This meeting was held in conjunction with the Cork Respiratory Faculty and featured ‘State of the Art’ lectures from key national and international experts. This was an outstanding event and many thanks to Boehringer Ingelheim for their support through an unrestricted educational grant. A key initiative under development in 2014 and into 2015 will be the establishment of Irish Thoracic Society Registry for Interstitial Lung Disease. This promises to provide much needed data on the prevalence, distribution, and longitudinal follow up of patients with IPF and other ILD in Ireland and may have applications to other respiratory diseases into the future. Thanks to Boehringer Ingelheim Ireland for their support on this initiative. Finally, a very special feature of this year’s meeting will take place as part of the Gala Dinner on Friday evening when it will be a great honour to present the Irish Thoracic Society Award for Outstanding Contribution to Respiratory Medicine to a very deserving and highly respected recipient who has contributed greatly to Respiratory Medicine in Ireland and beyond over a long career. The success of all these initiatives is only possible thanks to the support and engagement of our members, partner organisations and our partners from the pharmaceutical and medical equipment sectors. This support is hugely appreciated and we look forward to continued collaboration in 2015 and beyond. Have a great meeting!

Professor Anthony O’Regan President, the Irish Thoracic Society

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Thursday 6th November 13.00–17.00

Specialist Registrar (SpR) Training—Veranda Lounge Supported by Astra Zeneca through an unrestricted educational grant

19.00–20.30

ITS Case Study Forum—followed by dinner and prize for Best Case Presentation 2014—Inis Mor Suite 2 and 3 Supported by Astra Zeneca through an unrestricted educational grant

Chairs

MX FitzGerald, UCD JJ Gilmartin, Galway University Hospitals

19.00–20.00

Case Study Poster Review—Inis Mor Suite 2 and 3

20.00–20.50

Case Study Oral Presentations—Inis Mor Suite 2 and 3

20.00

1. A case of a forgotten disease post tonsillectomy M Ahmed, S Ahmed, W Shah, B Cushen, B Canavan, C McGurk St Luke’s Hospital, Kilkenny, Ireland

20.10

2.‘White out’ of Lung RP Cusack1, CG O’Leary1, LJ Chawke1, J McCarthy2, DR Curran1, TM O’Connor1 Departments of 1Respiratory Medicine and 2Gastroenterology, Mercy University Hospital, Cork

20.20

3. An unusual cause of Massive Haemoptysis Kelly R, O’Reilly K, Redmond K, Lawler L, Eaton D Departments of Thoracic Surgery, Respiratory Medicine and Radiology, Mater University Hospital, Dublin 7

20.30

4. Leading up the Garden Path? Moore I, Chapman N, Polley L, Convery R Craigavon Area Hospital, Southern Health and Social Care Trust

20.40

5. Rare case of Persistent Cough Thong L1, Khan KA1, O’Connor TM2, Kennedy MP1 1 Cork University Hospital/University College Cork, 2Mercy University Hospital Cork

21.00

Dinner and Prize-giving

Friday 7th November 07.30–08.00

Registration, tea and coffee, exhibition viewing—Inis Mor Suite

08.00–11.00

Poster Review and Parallel Discussions

08.00–09.30

Poster Review—Inis Mor Suite 2 and 3 and Veranda Lounge

09.30–11.00

Parallel Poster Discussions 1. Asthma and Sleep—Inis Mor Suite 2

Chairs

J. Faul, Connolly Hospital, Dublin JJ. Gilmartin, Galway University Hospitals, Galway 2. COPD Clinical—Inis Mor Suite 3

Chairs

K. Finan, Sligo Regional Hospital, Co Sligo M. Sheehy, Midland Regional Hospital, Mullingar, Co Westmeath 3. General Respiratory—Veranda Lounge

Chairs

T. McDonnell, St Vincent’s University Hospital Dublin M. Rogan, University Hospital Waterford, Co Waterford

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Chairs

4. Interstitial Lung Disease and Rarer Respiratory Disorders—Marinas Private Section D. O’Callaghan, Mater Misericordiae University Hospital, Dublin C. Rooney, Mayo General Hospital, Castlebar, Co Mayo

11.00–11.30

Tea and Coffee/Exhibition viewing—Inis Mor Suite

11.30–12.30

Oral Presentations I—Inis Mor Suite 2 and 3

Chairs

T. O’Connor, Mercy University Hospital Cork, Cork S. Donnelly, Adelaide and Meath Hospital (incorporating the National Children’s Hospital, Tallaght, Dublin 24

11.30

5.1. High prevalence of Non-Smoking related Obstructive Lung Disease in Farmers in Ireland B Cushen1, N Donoghue2, D Langan1, T Cahill1, E Nic Dhonnacha1, O Healy1, F Keegan1, M Browne3, I Sulaiman4, A O’Regan1 1 Department of Respiratory Medicine, Galway University Hospital 2 Department of Respiratory Medicine, Bon Secours Hospital, Galway 3 NUI Galway 4 Royal College of Surgeons in Ireland

11.40

5.2. Positional Therapy is a Cheap and Effective Alternative to Continuous Positive Airway Pressure in PositionAssociated Obstructive Sleep Apnoea DB Fitzgerald, LJ Chawke, JS O’Sullivan, M Rafferty, A O’Mahony, TM O’Connor, DR Curran Department of Sleep and Pulmonary Medicine, Mercy University Hospital, Cork

11.50

5.3. Inflammatory induced ER stress in Cystic Fibrosis neutrophils is reduced by ivacaftor treatment White M, Alfawaz B, Cox S, Hayes E, McElvaney NG, and Reeves EP Royal College of Surgeons, Ireland

12.00

5.4. Serum exosomes from IPF patients display a fibrotic miRNA profile and induce collagen production in vitro Rosemary Kane1*, Robert V. Lumsden1*, Sharon Whitty1, Denise Boylan1, Sinead Walsh1,2, Julie Worrell1, Faheem Khan 1,2, Seamas C Donnelly1,2, Marcus Butler 1,2, Aurelie Fabre 1,2, Michael P. Keane1,2 1 UCD Conway Institute of Biomolecular and Biomedical research, University College Dublin, Belfield, Dublin 4, Ireland. 2 Department of Respiratory Medicine, St Vincent’s University Hospital and School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland

12.10

5.5. Patient Experience of Pirfenidone Use at a Specialist ILD Clinic Subramaniam A, Elshafi M, Thong L, O’Halloran K, Bowen B, Khan KA, Murphy DM, Plant BP, Kennedy MP, Henry MT Department of Respiratory Medicine, Cork University Hospital

12.20

5.6. 100 Lung Transplants Delivered In Ireland Gough A, Wood AE, McCarthy JF, Nolke L, Healy DG, Redmond K, Eaton DR, Javadpour H, Egan JJ National Thoracic Transplantation Service, Mater Misericordiae University Hospital, Dublin 7, Ireland

12.30–13.00

ITS Guest Update—Inis Mor Suite 2 and 3 Supported by InterMune UK and Ireland through an unrestricted educational grant Pharmacological treatment of IPF in 2014 Prof Jim Egan, Consultant Respiratory Physician, Mater Misericordiae University Hospital

Parallel Business Meetings/Forums Friday 7th November 09.00–10.30

Primary Ciliary Dyskinesia Round Table Discussion—Joyce Suite

11.00–13.00

Forum of ANAIL—Association of Irish Nurses in Respiratory Care—Morris Suite Supported by Mundipharmaceuticals Ltd through an unrestricted educational grant

11.00–13.00

Forum of the IICMS Faculty of Respiratory (formerly IARS)—Joyce Suite

11.00–13.00

Forum of Chartered Physiotherapists in Respiratory Care—Darcy Suite

11.30–13.00

Irish Thoracic Society Paediatric Forum—Veranda Lounge

14.00–16.00

COPD Outreach Meeting—Veranda Lounge

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6. Irish Thoracic Society Paediatric Forum—Veranda Lounge D. Slattery, Children’s University Hospital, Temple St, Dublin

11.30

6.1 Paediatric Respiratory Non-invasive ventilation service Carrig C, Devitt M, McDonald M, Greally P Paediatric Respiratory Department, Tallaght Hospital, Dublin 24

11.38

6.2 Heated Humidified High Flow Nasal Cannualtion (HHHFNC) Therapy in the Treatment of Bronchiolitis F Kennedy, D Finn, B Elnazir Paediatric Dept., AMNCH Tallaght, Dublin

11.46

6.3. A Comparative study of two medication groups of infants with moderate bronchiolitis F.Yasin, Z.S.Afridi, R.Khan Paediatric Department, Kerry General Hospital Tralee, Ireland

11.54

6.4. Life-threatening post-fontan plastic bronchitis: a paediatric case report and literature review Tee WJ1, Franklin O2, Cox DW1 1 Respiratory Department, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland 2 Cardiology Department, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland

12.02

6.5. The effects of vitamin D supplementation on pulmonary function, disease severity and markers of inflammation in childhood asthmatics: a randomized, double-blind, placebo-controlled trial CP. Kerley1,2, K. Hutchinson3 P. Greally4, D. Coghlan4 and B. Elnazir4 1 Unversity College, Dublin, Belfield, Dublin 4 2 Respiratory and Sleep Diagnostics Department, Connolly Hospital, Dublin 15 3 Biomnis Ireland, Sandyford business Estate, 3 Rock Rd, Dublin 4 The Adelaide and Meath Hospital, Dublin

12.10

6.6. Comparison of Two Methods of Inhaler Technique Instruction in Children S Arthurs, R Khan, F Yasin, E Cahalane, J Cournane, B Browne and R O’Shea Physiotherapy and Paediatric Departments, Kerry General Hospital

12.18

6.7. 5 Year Review of First Time Colonisations of Pseudomonas Aeruginosa in Children with Cystic Fibrosis: Treatment and Outcomes D Finn, G Leen, B Elnazir, Respiratory Dept, AMNCH, Tallaght

12.26

6.8. Determing the lung clearance index of children with cystic fibrosis, aged 4–16 versus healthy subjects in an irish setting Keane L1, Linnane B2, Saunders J3,4, Zeugolis, D5 1 Centre for Adult Learning and Professional Development, 2 University Hospital Limerick, 3 Statistical Consulting Unit, University of Limerick, 4 Centre for Support and Training in Analysis and Research CSTAR Limerick, 5 Network of Excellence for Functional Biomaterials, National University of Ireland

12.34

6.9 Mycobacterium africanum and disseminated TB in childhood: a case illustrating a rare presentation in the immunocompetent host S Giva1, S Geoghegan1, C Hickey2, C Bogue3, TM O’Connor4, D Mullane1, SM O’Connell1 Departments of 1Paediatrics and Child Health, 2Microbiology and 3Radiology, Cork University Hospital and 4Department of Respiratory Medicine, Mercy University Hospital

12.45

Irish Thoracic Society Paediatric Forum Guest Lecture A bluffer’s guide to Primary Antibody Deficiency Dr Ronan Leahy, Consultant in Paediatric Immunology and Infectious Diseases, Our Lady’s Children’s Hospital, Crumlin and Children’s University Hospital, Temple St. Honorary Senior Lecturer, Royal College of Surgeons in Ireland

13.30–14.00

Meeting of ITS Paediatric Special Advisory Panel

13.00–14.15

Lunch—Marinas Restaurant

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14.00–16.00

COPD Outreach Meeting—Veranda Lounge

14.00–14.30

Asthma COPD Overlap Dr Robert Rutherford, Consultant Respiratory Physician, Galway University Hospitals

14.30–16.00

Business Meeting of the COPD Outreach Group

14.15–15.45

Oral Presentations II—Inis Mor Suite 2 and 3

Chairs

A. O’Brien, University Hospital Limerick M. Kelly, Altnagelvin Hospital, Derry

14.15

7.1. Objective quantification of both time and technique of dry powder inhaler use by a community based population of respiratory patients Sulaiman I1, Seheult J1, MacHale E2, D’Arcy S3, Boland F4, Aman A1, Abdullah M1, McCrory K5, Casey J6, Bury G7, McCarthy C1, O’Brien ME1, Meurling IJ, Al-Alawi M1, Reilly RB3, Costello RW1 1 Department of Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; 2Respiratory Department, Clinical Research Centre, RCSI, Dublin, Ireland; 3Trinity Centre for Bioengineering, Trinity College, University of Dublin, Ireland; 4RCSI Population Health Sciences, RCSI, Dublin, Ireland; 5 Primary Care Practice, Finglas Family Practice, Dublin, Ireland; 6 Primary Care Practice, Beaumont Park Clinic, Beaumont Woods, Dublin, Ireland; 7 Primary Care Practice, Coombe Medical Centre, Dublin, Ireland

14.25

7.2. Lower FEV1 and MMEF25–75 and higher eosinophil counts predict airway hyperresponsiveness in patients with suspected asthma O’Sullivan JS, Chawke LJ, Fitzgerald DB, Curran DR, O’Connor TM Department of Respiratory Medicine, Mercy University Hospital, Cork, Ireland

14.35

7.3. Effect of continuous positive airway pressure (CPAP) on blood pressure in patients with obstructive sleep apnoea (OSA) and resistant hypertension Judge, C 2; Daniels, F 1; Byrne, Carroll 1; Kyvelou, S 1; Healy, O 1; Garvey, J 2; Sharif, F 1; Gilmartin, JJ 2 [1] Department of Cardiology, Galway University Hospital, Newcastle Rd., Galway [2] Department of Respiratory Medicine, Merlin Park University Hospital, Dublin Rd., Galway

14.45

7.4. Planting the seed: introducing advanced care planning information during Pulmonary Rehabilitation B. Korn, R. Kennedy, M. Scanlan and R. O’Donnell, Department of Respiratory Medicine, St. James’s Hospital, Dublin

14.55

7.5. COPD Satellite Clinic: Does Integrated Care Work For Obstructive Lung Disease? Johnston J.a, O’Toole P.a, Gallagher J.b, O’Doherty B.c, and Mc Donnell T.J.a a. COPD Outreach Service and Dept. of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin b. The Palms Surgery, Gorey, Co Wexford c. Gorey Medical Centre, Gorey, Co. Wexford

15.05

7.6. The acute and chronic effects of dietry nitrate on exercise tolerance in COPD patients CP. Kerley1,2, Bolger K1, Cahill K1, A McGowan2, A O’Brien2, K Fennell2, J Faul1,2, L Cormican1,2 1 Respiratory & Sleep Diagnostics Department, Connolly Hospital, Dublin 15 2 School of Medicine, University College Dublin

15.15

7.7. Gremlin1 and vascular endothelial growth factor signalling in the lung Rowan SC1, Cornwell J1, McLoughlin P1 1 School of Medicine and Medical Sciences, Conway Institute, UCD, Belfield, Dublin 4

15.25

7.8. The use of Radial Probe EBUS in diagnosis of Peripheral Lung Lesion L. Khorsheed1, KA. Khan1, J McCarthy 2, L Burke3, MT Henry1, MP. Kennedy1 Departments of Respiratory Medicine, Cytopathology and Histopathology, Cork University Hospital, Cork

15.35

7.9. Effect of cigarette smoking on human pulmonary immunity during Mycobacterium tuberculosis infection Seo´nadh M. O’Leary1, Michelle M. Coleman1, Wui Mei Chew1, Colette Morrow2, Anne-Marie McLaughlin3, Mary P. O’Sullivan1, Joseph Keane1,3 1 Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, Dublin, 2Dublin Centre for Clinical Research, St James Hospital, 3Department of Respiratory Medicine, St James Hospital, Dublin, Ireland

15.45–16.15

Tea and Coffee/Exhibition viewing—Inis Mor Suite

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Irish Thoracic Society Guest Lecture—Inis Mor Suite 2 and 3 Supported by Boehringer Ingelheim Ireland through an unrestricted educational grant Making wise decisions in respiratory medicine based on patient data Prof Martin Tobin, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Hines VA Hospital and Loyola University of Chicago Stritch School of Medicine

Chairs

R. Costello, RCSI, Beaumont Hospital, Dublin B. Canavan, St Luke’s General Hospital Kilkenny

17.30–18.30

Irish Thoracic Society AGM—Veranda Lounge

19.00–20.00

Irish Thoracic Society Drinks Reception—Hotel Lobby Sponsored by BOC Healthcare

20.00–Late

Irish Thoracic Society Gala Dinner and Award for Outstanding Contribution to Respiratory Medicine—Inis Mor Suite 2 and 3

Saturday 8th November 07.30–08.00

Registration, tea and coffee, exhibition viewing—Inis Mor Suite

08.00–10.45

Poster Review and Parallel Discussions

08.00–09.30

Poster Review—Inis Mor Suite 2 and 3 and Veranda Lounge

09.30–10.45

Parallel Poster discussions 8. Lung Cancer—Inis Mor Suite 2

Chair

R. Morgan, Beaumont Hospital, Dublin 9. COPD Basic Science—Inis Mor Suite 3

Chair

M. Butler, St Vincent’s University Hospital, Dublin 10. TB and Other Infections—Veranda Lounge

Chair

J. Keane, St James Hospital, Dublin TBC 11. Cystic Fibrosis and Bronchiectasis—Marinas Private Section

Chair

R. Rutherford, Galway University Hospital

10.45–11.15

Tea and Coffee/Exhibition viewing

11.15–12.00

ITS Guest Lecture—Inis Mor Suite 2 and 3 Supported by Vertex through an unrestricted educational grant Information Technology and Healthcare Dr Ronan Kavanagh, Galway Clinic

Chair

R. Rutherford, Galway University Hospital

12.00–13.00

ITS Pro Con Debate—Lung Cancer Screening—Inis Mor Suite 2 and 3 Supported by Boston Scientific through an unrestricted educational grant

Pro

Dr James Jett MD, Director, Clinical and Translational Research Section, Division of Oncology, National Jewish Health, Denver, Colorado

Con

Dr Cyrus Daneshvar, Consultant in Respiratory Medicine, Plymouth University Hospitals Trust

Chair

D. Breen, Galway University Hospital

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 Prize giving and close Awards for Best Oral and Poster Presentations Supported by Boehringer Ingelheim Ireland through an unrestricted educational grant Presentation of ANAIL Award for Best Presentation by a Respiratory Nurse Presentation of the ITS Research Grant in Respiratory Medicine 2014 Supported by GSK through an unrestricted educational grant

13.15

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Irish Thoracic Society Poster Review and Discussion Friday 7th November 2014

1. Asthma and Sleep Chairs

J. Faul, Connolly Hospital, Dublin JJ. Gilmartin, Galway University Hospitals, Galway

1.1. Persistence of Benefit Six Months after Discontinuation or Weaning of Omalizumab in a Responder Population of Severe Asthmatics D. Watchorn, A. Sahadevan, C. MacMahon, J. O’Callaghan, S.J. Lane Department of Respiratory Medicine, Tallaght Hospital, Dublin 24, Ireland Omalizumab is a recombinant humanised monoclonal antibody indicated in severe persistent asthma. Evidence suggests that longterm treatment with omalizumab has disease-modifying activity but data on optimum duration of treatment are lacking. The practice in our centre is to trial weaning of this therapy (reduction in frequency of administration, or discontinuation) after 36 months of treatment. This study retrospectively examined the persistence of benefit in exacerbation frequency, peak expiratory flow rate (PEFR), and rescue bronchodilator requirements, 6 months after weaning of omalizumab in patients deemed responsive to this therapy and who underwent at least 36 months’ treatment. Baseline data were obtained from assessments carried out 6 months prior to weaning. Descriptive statistics were used and means were compared with Wilcoxon Signed Rank Test. Tweleve patients underwent weaning of omalizumab. No statistically significant difference was observed in exacerbation frequency, PEFR, or rescue bronchodilator use 6 months after weaning compared with 6 months prior (p = 0.657, p = 0.575, p = 0.5 respectively). No rebound effect or deterioration in asthma control was observed 6 months after weaning. Our data add to evidence that long-term treatment with omalizumab may have disease-modifying activity. Further study is needed to determine the optimum duration of treatment.

1.2. Determination of the Prevalence of Asthma/Atopy in a Defined Irish Sarcoidosis Cohort P Mitchell1, E.B. Hunt1,2, S. Hay1, M. Stack1, M.K. Kennedy1,2, B.J. Plant1,2, M.T. Henry1,2, D.M. Murphy1,2 Cork University Hospital/University College Cork, Cork1, HRB Clinical Research Facility, University College Cork, Cork2 Certain patients with sarcoidosis exhibit improved pulmonary function with bronchodilators. It is unclear as to whether observed improvement is due to co-existant asthma or simply improvement in sarcoid related inflammation. Our aim was to determine the prevalence of asthma/atopy in a defined Irish sarcoidosis cohort, and determine if exhaled nitric oxide (FENO) has a role in defining such patients.

S495 Patients were recruited prospectively at the time of diagnostic bronchoscopy and were subjected to FENO measurement, pulmonary function tests, and blood analyses. Twenty-nine patients with newly diagnosed sarcoidosis were recruited. Using a complete diagnostic workup, coexistent asthma was diagnosed prospectively in 2/19 patients (11 %), and with partial diagnostic data, asthma was present in 2/26 patients (8 %). Prevalence of asthma in our cohort lies between 8 and 11 %. Coexistent atopy was present in 14/26 cohort patients. There was no significant difference between FENO values and asthma (p = 0.549) or atopy (p = 0.931). This study demonstrates coexistent asthma/atopy in a defined Irish sarcoidosis cohort similar to prevalence estimates in the general population. Our data suggest FENO is not a clinically useful diagnostic tool for distinguishing between sarcoidosis patients with asthma/ atopy, and those without.

1.3. Living with Asthma: Patient Accounts of Everyday Life in Ireland M. Hughes, M. Dunne Research and Education, Asthma Society of Ireland, Dublin School of Nursing and Midwifery, University College Cork, Cork The aim of this study was to investigate the quality of life of Irish adults who have asthma, with particular interest on the influences to their health and wellbeing. Participant perceptions of the Asthma Society of Ireland (ASI) were also explored. Irish people have a history of recording high levels of satisfaction with their health (1). Reduced quality of life is frequently the cause of unscheduled attendance at a healthcare provider, and may not necessarily be due only to an increase in asthma symptoms (2). This qualitative enquiry involved participant focus groups. The study population were a convenience sample recruited from our database of members. Participants reported that asthma had a profound impact on their quality of life, irrespective of their perceived level of control. There were multiple factors influencing their quality of life. They were satisfied with their association to ASI. This study could facilitate a change in service provision by health professionals in addressing the needs of the asthma population. Findings suggest that functional or physical status or measurement of symptom control should not be considered as the only measure in how people with asthma rate their quality of life. Health and wellbeing should be addressed as separate, yet co-existing requirements in optimising the quality of life of people with asthma. This research was kindly sponsored by Boehringer Ingelheim. Reference: 1. Department of Health. Health in Ireland: Key Trends 2013. Dublin 2013 2. Eberhart NK, Sherbourne CD, Edelen MO, Stucky BD, Sin NL, Lara M (2014) Development of a measure of asthma-specific quality of life among adults. Qual Life Res, 23(3):837–848

1.4. Distribution of Aeroallergen Sensitization and Risk of Cross-Sensitization in an Asthma Centre A. Sahadevan, D. Watchorn, M. Kooblall, S. Lane Department of Respiratory Medicine, AMNCH Tallaght 2014

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Sublingual immunotherapy has proven to be effective in managing allergic rhinitis (AR) and potentially asthma. Aeroallergen avoidance and therapeutic intervention in both diseases are guided by skin prick testing (SPT).Our aim was to delineate the pattern of allergen sensitization in a cohort of patients with AR. Second question was to calculate the pattern of cross reactivity in the AR group. A retrospective analysis of 2 years SPT on patients with AR in an asthma centre was performed (n = 186). Pattern of allergen sensitization Allergen

Percentage (n = 186)

House dust mite HDM

85 %

Grass pollen GP

60 %

Cat dander

49 %

Dog dander Tree pollen

49 % 14 %

Horse

14 %

Polysensitised (2 or more)

68 % [126]

HDM monosensitized

19 %

GP monosensitized

8%

Pattern of cross-sensitization of HDM induced AR Risk of cross-sensitization to

Risk in percentage (%)

GP

47.8

Cat dander

38.2

Dog dander

34.9

Horse Tree pollen

12.9 11.8

1.5. Safety of Specific Sublingual Immunotherapy in an Irish Asthmatic Population A. Sahadevan, D. Watchorn, J. O’Callaghan, F. McMullan, S.J. Lane Department of Respiratory Medicine, AMNCH Tallaght 2014 Allergic rhinitis (AR) is a common condition affecting approximately 40 % of the Irish asthmatic population. Sublingual immunotherapy (SLIT) is indicated in the treatment of AR. Sublingual immunotherapy is currently only licensed in allergic rhinitis patients with mild asthma. There is some evidence that SLIT improves asthma control [1]. Our study sought to evaluate changes in asthma control (by GINA assessment) in AR patients (n = 30) prior to and 6 months after commencing grass pollen SLIT. Six months after commencing grass pollen SLIT, asthma control (by GINA assessment) improved in 15 patients, remained stable in 12 patients and disimproved in three patients. These results are statistically significant by Wilcoxon Signed Rank Test (p = 0.01). These results are limited by the small number of patients studied and the heterogeneity of the study population, but suggest that SLIT did not adversely affect asthma control over a 6-month treatment period in a population of Irish asthmatics. Reference: 1. Lin SY (2013) Sublingual immunotherapy for the treatment of allergic Rhino conjunctivitis and asthma. JAMA

1.6. High Prevalence of Allergic Rhinitis in Young Adults in Ireland A.W. O’Regan1, D. Gilmore3, A. Purcell1, A. Garrahy1, V. Tormey2 1

Department of Respiratory Medicine, Galway University Hospital, Department of Immunology, Galway University Hospital, 3Graduate Entry Medical School, University of Limerick

2

Pattern of cross-sensitization of GP induced AR Risk of cross-sensitization to

Risk in percentage (%)

HDM

47.8

Cat dander

34.4

Dog dander

25.3

Horse

12.4

Tree pollen

11.8

Cross sensitization is very common, and it is important to correlate clinical effect and potential silent sensitization without respiratory symptoms. Reference: 1. Lin SY, Erekosima N, Kim JM, Ramanathan M, Suarez-cuervo C, Chelladurai Y, et al (2013) Sublingual Immunotherapy for the treatment of allergic rhino conjunctivitis and asthma. JAMA, 309(12)

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Background: Asthma and nasal disease is common in developed countries. In Ireland Asthma prevalence exceeds 10 % but little is known about upper airway disease. We hypothesized that allergic nasal disease is common in young adults. Methods: We performed a cross-sectional study of the prevalence of allergic rhino-sinusitis, and related symptoms in patients attending the sexually transmitted infection clinic at Galway University Hospital. As patients attending this clinic are not presenting with respiratory complaints, they are representative of the general population. Results: 47 (95 % of patients attending the clinic) participated. Average age was 26 + 6 and 28 (60 %) were male. 35 patients were Irish born. 17 (36 %) and 12 (25 %) reported a prior diagnosis of allergic rhinitis/sinusitis or asthma respectively. 28 (60 %) described symptoms consistent with allergic rhinitis, with a strong association with the summer season. Triggers included pollen 18 (38 %), grass/ hay 19 (40 %), dust 21 (44 %), pets 13 (27 %). 44 % reported a family history of hay-fever.

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 Conclusion: This is the first cross-sectional study of the prevalence of allergic rhinitis in a cohort of subjects representative of the general population. There is a remarkably high prevalence of symptoms consistent with allergic rhinitis. This may reflect the high pollen counts experienced during this time of this study.

1.7. Work Related Respiratory Ill Health (WRRIH): Republic of Ireland, Northern Ireland, Great Britain 2005–2012 A. Money, M. Carder, J.P. Hayes, P. Noone, P. Bourke, J. Hayes, R. Agius Centre for Occupational and Environmental Health, Centre for Epidemiology, University of Manchester UK Data on WRRIH in the ROI is inconsistent. We compared the incidence of WRRIH reported by respiratory physicians (RP) in ROI, NI and GB between 2005 and 2012. Data reported to the three surveillance schemes was analysed. Data collection in ROI has been inconsistent but remains a requirement under ILO and Eurostat regulations. Data are collected through the SWORD scheme using exclusively electronic reporting methodology. The annual average incidence rates for RPs reporting respiratory disease in ROI were 1 (95 % CIs 0.3, 1) per 100,000 employed. Adjusting for ‘non-participation’ and non-response this increased to to 32 (95 % CI 28.4, 35.6). This compared to respective incidence rates of 8 (95 % CIs 6.1, 10.7) and 15 (CIs 11.3, 19.6) per 100,00 in GB. In ROI, RPs reported proportionately more cases of asthma while RPs in GB and NI reported larger proportions of non malignant pleural disease and mesothelioma. In all three geographical areas construction and manufacturing were the two industrial sectors most frequently reported. Isocyanates were the most common cause of asthma. Assuming a working population of 1.9 million, these data indicate greater than 600 cases of WRRIH in ROI per annum. THOR-ROI remains an important source of WRRIH in ROI.

1.8. The Prevalence of Respiratory Symptoms among Mushroom Workers in Ireland

S497 suggest that as many as 22 workers had symptoms of airways disease, 18 (82 %) of these were mushroom growers. Growers were significantly more likely to have symptoms consistent with airways disease when contrasted with all other workers odds ratio 9.16 (95 % CI 2.96–28.4). There is a high prevalence of respiratory symptoms among mushroom workers.

1.9. The Effects of Vitamin D Supplementation on Neuropyshological Function, Insulin Resistance, Inflammation and Subjective Indices of Mood, Fatigue and Sleep: a Pilot Study C. Kerley1,2, K. Hutchinson3, J. Faul1,2, L. Cormican1,2 1 Respiratory and Sleep Diagnostics Department, Connolly Hospital, Dublin 15, 2School of Medicine, University College Dublin, 3Biomnis Ireland, Sandyford business Estate, 3 Rock Rd, Dublin

Our group and others have reported a high rate of vitamin D deficiency in obstructive sleep apnoea syndrome (OSAS), where vitamin D levels (25(OH)D) correlate negatively with AHI and glucose metabolism. In Autum/Winter 2013 we recruited 26 adults (20 male, aged 55.2 years ± 12, BMI: 30.4 kg/m2 ± 5.6) with PSG proven OSAS (Dublin, Ireland, 53). At baseline we assessed quality of life with the Epworth Sleepiness Scale (ESS) and Sleep Apnoea Quality of Life Inventory (SAQLI). We assessed neuropsychological function with trail making B test and Connor’s Continuous Performance Test II (CPT II). In addition, we assessed biochemical indices of vitamin D status (25(OH)D, calcium), inflammation (hsCRP), cholesterol (LDL, HDL) and glycaemic indices (fasting glucose, oral glucose toelrance test). The intervention was 15 weeks of 4,000 iu vitamin D3/day or matching placebo. There was no change in medication or CPAP. Compliance was high (*93 %) and there were no adverse effects. There were 7 dropouts, leaving 19 subjects who completed all assessments. Table 1 displays absolute change in variables from baseline to endpoint from these 19 completing subjects. Table 1: Absolute changes from baseline to endpoint Placebo

Vitamin D3

N=

9

10

Male: Female

8:1

6:4

CPAP users 25(OH)D

6 (66.6 %) -5.5 ± 23

9 (90 %) 67 ± 35

Calcium

-0.05 ± 0.2

0.09 ± 0.06

0.05

Fasting glucose

0.5 ± 1.8

-0.4 ± 0.6

0.09

Glucose excursion

0.4 ± 0.9

-1.8 ± 6.6

0.3

HDL

-0.08 ± 0.1

0 ± 0.1

0.07

LDL

0.4 ± 0.9

-0.3 ± 0.6

0.04

CRP

-0.6 ± 1.5

-1.3 ± 2.4

0.2

ESS

-2.6 ± 4.7

-4.5 ± 4.2

0.1

SAQLI (symptom score)

1.3 ± 4.8

2.8 ± 6.8

0.3

Tralin making B (s)

10.4 ± 76

-12.6 ± 12

0.1

CPT II Omission T score

0 ± 14.7

-5.9 ± 18.9

0.2

J.P. Hayes1, J. Rooney2 Department of Respiratory Medicine1, Cavan-Monaghan Hospital, Trinity Bioscience Institute2 Dublin Respiratory conditions such as asthma, bronchitis, hypersensitivity pneumonitis and upper airways symptoms have been ascribed to fungal exposures in mushroom workers. A cross-sectional study assessed 4 weeks of respiratory symptoms among 191 mushroom workers divided into four categories of exposure. A self-administered respiratory questionnaire was completed and spirometry was performed. The population was predominantly (66 %) from Eastern Europe; 61 % were women and 39 % were under 30 years old. Included were 73 growers, 38 composters, 26 administrators and 52 packers. Amongst all workers, there was a high prevalence (67 %) of one or more respiratory symptoms which did not appear to vary by age, gender, pack-years of smoking or duration of employment. There was a significant improvement in respiratory symptoms in workers during absence from the workplace (p \ 0.001). Spirometry readings across all groups were within normal values. Symptom profiles

*P value

0.00001

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

Values presented are mean ± standard deviation * P values are derived from 1 tailed, unpaired T tests In conjunction with a significant increase in 25(OH)D levels, vitamin D supplementation was associated with improved quality of life, as well as metabolic and neuropsychological indices compared to placebo. Vitamin D replenishment warrants further investigation as a adjunct therapeutic strategy in OSAS. This work was supported by the Irish Lung Foundation.

Nocturnal dietary nitrate may improve NO bioavailability in OSAS, resulting in BP benefits. We have recently commenced a double-blind, randomized, placebo-controlled crossover trial to assess the value of chronic, nocturnal dietary nitrate in OSAS

1.11. Mallampati Score as an Independent Predictor of Obstructive Sleep Apnoea (OSA) J. Alam, A. Russell, S. Ryan, W.T. McNicholas

1.10. Nocturnal Dietary Nitrate for Obstructive Sleep Apnoea: A Pilot, Randomized, Controlled, Crossover 2 week Trial C.P. Kerley1,2, E. Dolan3, J. Bramham4, J.L. Faul1, L.J. Cormican1 1 Respiratory and Sleep Diagnostics Department, Connolly Hospital, Dublin 15, 2School of Medicine, University College Dublin, 3 Department of Geriatrics, Connolly Hospital, Dublin 15, 4School of Psychology, University College Dublin

Obstructive sleep apnoea syndrome (OSAS) is associated with high blood-pressure (BP), absence of nocturnal BP dipping and decreased cerebral blood-flow [1] leading to an increased risk for cardiovascular and neurocognitive morbidities. The bioavailability of nitric oxide (NO), a vasodilator, is indicated by serum nitrate/nitrite, which are typically decreased in OSAS [2]. Dietary nitrate may increase serum nitrate/nitrite, lower BP, and increase cerebral blood-flow. 3 CPAP naı¨ve males (mean age 53.3 years; mean BMI 38.1 kg/ m2) with severe, untreated OSAS (mean AHI 34) completed the Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), a neuropsychological assessment including trail making tasks A and B. In addition, an ambulatory BP monitor was worn for 24-h. Subjects were randomized to either 140 ml beetroot juice (BRJ) (12.7 mmol nitrate) nightly or 140 ml water (\0.5 mmol nitrate) nightly for 2 weeks followed by the crossover condition. Assessments were repeated at 2- and 4-weeks. No adverse effects of dietary nitrate were reported. We observed a trend towards improvements in mood, fatigue, sleepiness as well as significant improvements in neuropsychological function (p = 0.004) and blood pressure dipping (p = 0.02).

Mallampati (MP) scoring is a simple non-invasive method of assessing oral airway size. Here, we test the hypothesis that MP assessment is useful in the evaluation of obstructive sleep apnoea (OSA). We performed a retrospective study of 212 consecutive patients (Pts) who were evaluated for OSA in our centre. OSA was defined as an apnoea/hypopnoea index (AHI) C5/h. Data were collected from sleep data base and medical records. SSPS 17 was used for statistical analysis. Mean age was 50 ± 13 years, BMI 32.4 ± 6.4 and 74 % were male. 63 % were diagnosed with OSA. MP significantly correlated with AHI (r = 0.299; p \ 0.001), both in male and female and in linear regression, MP remained a significant predictor after adjustment for other demographic and anthropometric parameters. A MP of 3 and 4 was associated with the presence of OSA in 80 % (PPV), and a score of 1 and 2 with the absence of OSA in 48 % (NPV). Mallampati (MP) score correlates with OSA severity. The clinical usefulness of assessing MP prior to sleep studies warrants further investigation.

1.12. Prevalence of Cardiovascular Co-morbidities in an Outpatient Sleep Apnoea Cohort L. O’Neill, F. Doody, M. Hensey, M. Rogan, S. Foley Department of Respiratory Medicine, Waterford Regional Hospital

Differences between water and BRJ Baseline

Water

BRJ

* P value

FSS (0–60) ESS (0–24)

45 13

54 14

28 5

0.08 0.1

BDI (0–63)

13

14

3

0.1

Trail making A (s)

30

32

27

0.004

Trail making B (s)

51

60

35

0.1

Nocturnal SBP (mmHg)

118

122

106

0.08

Nocturnal DBP (mmHg)

71

74

67

0.06

% dipping SBP

-1.3

-0.3

7.5

0.02

Serum nitrate

39.9

181.5

42.9

0.009

Values presented are means * P values are derived from paired T-tests of the delta values between the interventions

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Department of Respiratory/Sleep Medicine St. Vincent University Hospital, Elm Park Dublin 4

Obstructive sleep apnoea (OSA) has a strong association with obesity and cardiovascular disease. We audited patients presenting to the OSA clinic in Waterford Regional Hospital to assess the prevalence of cardiovascular co morbidities in an Irish outpatient cohort. One hundred and ten patients were audited over a 10 week period, through direct interviewing and chart review. The average age was 52.6 ± 13.5 years. Fifty-six were new patients and 54 reviews. Eighty-five patients were referred by GPs. Six patients were referred from the Cardiology outpatient service. Thirty-seven patients were established on CPAP. Eight-seven patients (79 %) had an elevated BMI, 38 in the range of 30–40 and 16 [ 40 kg/m2. Fifty-four patients (49 %) had a diagnosis of hypertension and 51 were taking anti-hypertensive medications. Twentynine were taking multiple anti-hypertensives. Thirteen patients (11.8 %) had pre-existing atrial fibrillation, 10 (9 %) had ischaemic heart disease, 18 (16.4 %) were on treatment for hypercholesterolaemia and 17 (15.4 %) had diabetes mellitus. Multiple co-morbidities were present in 61 (55.4 %).

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

S499

There is a high prevalence of obesity and hypertension in outpatient OSA patients. It may be worth screening patients with such co morbidities for OSA in the cardiology outpatient setting.

1.15. Improving the Identification of Patients with Obstructive Sleep Apnoea: a New Screening Tool for High Risk Populations; Introducing Merlin

1.13. Sleep-Disordered Breathing in Heart Failure Patients Requiring Cardiac Resynchronisation Therapy

A. Mohamed Ahmed1, I. Vellinga2, Sulaiman1, K. Sharma1, J. Garvey1, J.J. Gilmartin1

M. Barrett, R. Cusack, A. O’Brien, T. Kiernan Department of Cardiology, University Hospital Limerick, Deptartment of Respiratory Medicine, University Hospital Limerick

We sought to ascertain the burden of undiagnosed sleep-disordered breathing (SDB) in high-risk heart failure patients, namely patients requiring cardiac resynchronisation therapy (CRT). Additionally, we looked for correlation between presence of SDB and change in cardiac function pre- and post-device From a population of 40 patients, a stable group of 12 were selected. Polysomnography was undertaken in each case. Apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), sleep efficiency, minimum oxygen saturation and snore index were calculated. Comparison was made to left ventricular function, left atrial dimension and mitral regurgitation severity. Our population had a high AHI (mean 14.3) and ODI (15.5) with poor sleep efficiency (mean 66 %). 3 patients (25 %) were classified as severe OSA (AHI [ 30), and 5 (42 %) had mild to moderate OSA. Patients were subdivided into those with improved cardiac function post-implant (n = 6) and those with unchanged function (n = 6). Median AHI was greater in the group without improvement in cardiac function (12.05 vs. 6.9, p = 0.10). There is a high prevalence of SDB in our cohort with a trend towards more severe sleep apnoea in non-responders to CRT. Treatment of sleep apnoea may have an role in optimising outcomes.

1.14. The Role of Oximetry and C-PAP Titration in Patients with Obstructive Sleep Apnea in Ireland

1

Department Respiratory Medicine, Merlin Park University Hospital, Galway, 2Department of Medicine, National University of Ireland, Galway

1.16. Pulse Oximetry in Sleep Diagnostics: a Comparison between Devices at Either End of the Cost Spectrum A. Byrne, P. Coss, M. Varghese, A. Martin Department of Respiratory Medicine, St. James’s Hospital, Dublin 8 Pulse Oximeters are available for purchase in the non-clinical market in the absence of any minimum standards or purchasing guidelines. For example, the British Hypertension Society publishes a list of approved blood pressure monitors for use in the home setting. SpO2 during ‘spot checks’ and the Oxygen Desaturation Index (ODI) from an oximeter purchased on eBay were compared simultaneous, with hospital oximeters in a variety of clinical settings including: in-house Polysomnography (PSG) and home overnight oximetry (HO). Bland and Altman analysis (BA) was then performed. The eBay wrist Oximeter (including analysis software and internal memory) cost 7 % of the equivalent hospital oximeter in the study. The following table summarises the BA analysis

n = 76

Spot check SpO2

HO (ODI)

PSG (ODI at 4 %)

PSG (ODI at 3 %)

Bias (%)

1.3

1.4

0.04

0.98

Limits of agreement (+)

3.3

9.7

15.6

20.1

M. Kooblall, J. Bykova, S. Lane, E. Moloney

Limits of agreement (-)

0.8

6.8

15.5

18.2

Respiratory Department Tallaght Hospital and Peamount Hospital

The results suggest a clinically significant difference in SpO2 and ODI between the ‘eBay’ Oximeter and the hospital standard. The limits of agreement in all study conditions are wide so the results are ambiguous from the trial oximeter. This study suggests the need for purchasing guidelines and minimum standards for pulse oximeters in the non-clinical marketplace.

Obstructive Sleep Apnea (OSA) is estimated to affect one in five adults (approximately 100,000 adults in Ireland). Waiting time for a PSG can take several months. A retrospective charts review of 48 consecutive referrals to peamount healthcare were examined. Demographics, clinical assessment and oximetry results were recorded. All 48 patients were given a CPAP trial for 2 consecutive days and their oximetry data and Epworth sleep score were compared at admission and at day 2. 32 (67 %) patients had a desaturation index of \15 % on their oximetry and ESS [ 11. After 2 days of C-PAP trial, all these 32 patients again had a 100 % improvement (Desaturation Index \5 %) and ESS \ 11. 16 (33 %) patients with inconclusive results were referred for full PSG and 5 (10 %) patients were diagnosed with OSA. Our retrospective study has shown to reduce waiting time for PSG at Peamount healthcare. With only 33 % of patients being referred for PSG, this study shows that 67 % were diagnosed and started on C PAP within a few weeks from their referral date. Reference: RCPI Medical Workforce planning Feb 2014;198

1.17. Patient’s Attitudes, Beliefs and Satisfaction with Domiciliary Non-invasive Ventilation (NIV) A. Scott, T. Cahill, D. Langan, N. Mcdonnell, P. Ridge, J.F. Garvey, A. O’Regan Department of Respiratory Medicine, Galway University Hospitals, Galway Domiciliary NIV has become an important treatment modality for patient with certain respiratory disorders, but do we ever ask what users think of it?

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S500 The database of NIV users in our catchment area contains 137 patients. Data was collected via a phone based questionnaire by which we collected 85 responses. 56 % of respondents were male. The mean age for men was 63 and women was 59 years. 55 % of respondents said that their quality of life (QoL) was much improved since starting NIV. 87 % of respondents said that they never forgot to use their NIV. 22 % required assistance setting up their machine. When asked about the company providing the machine, 89 % had a contact number and 58 % thought the support provided was excellent. 45 % thought the mask was comfortable. When asked what they would do if the NIV machine stopped working, 52 % said they would call the company the next morning and 16 % said they would turn it off and on. Overall our cohort feels that NIV has improved their QoL and a subjective assessment of compliance suggests that it is good. The majority can use NIV comfortably with suppliers playing an important role in the provision of technical support.

1.18 Nasal Symptoms are Common in Farmers in Ireland T. Cahill1, B. Cushen1, N. Donoghue2, D. Langan1, E. Nic Dhonnacha1, O. Healy1, F. Keegan1, M. Browne3, I. Sulaiman4, A. O’Regan1 1

Department of Respiratory Medicine, Galway University Hospital, Department of Respiratory Medicine, Bon Secours Hospital, Galway, 3NUI Galway, 4 Royal College of Surgeons in Ireland

2

Studies performed in other countries report a high prevalence of respiratory symptoms in farmers. We aimed to characterize the prevalence, nature and associations of respiratory symptoms in farmers in Ireland We undertook a cross-sectional assessment of farmer’s lung health at the 2013 Ploughing Championships. We used investigator-

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 delivered questionnaires to determine the prevalence of respiratory complaints and record general and farming specific risk factors for lung health. Of 402 volunteers, data from 381 was suitable for analysis. 62.9 % reported respiratory symptoms, the most common being cough (32 %), sputum production (20 %) and dyspnoea ± wheeze (32 %). 40 % reported upper respiratory tract/nasal symptoms predominantly nasal congestion (26 %) and anosmia (18 %). The presence of symptoms positively correlated with previous history of respiratory disease (p \ 0.05). There was a trend towards increased chest infections (2+/year) in those exposed to fossil fuels (p = 0.09). These patients and those reporting nasal symptoms were significantly more likely to require antibiotics (p \ 0.005; p = 0.021, respectively). There is a high prevalence of nasal disease in Irish farmers. It is likely that these symptoms relate to allergic or irritant nasal disease, and may demonstrate a shift toward airways disease from HSP in farmers in this country. Further studies are needed.

1.19 Plume Characteristics of Fluticasone Propionate/ formoterol pMDI Compared with Fluticasone Propionate/Salmeterol pMDI Baljinder Johal1, Seamus Murphy2, Jonathan Marshall3 1

Mundipharma Research Ltd, Cambridge UK; 2Oxford Lasers Limited, Oxon UK; 3Mundipharma International Limited, Cambridge UK

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

Irish Thoracic Society Poster Review and Discussion Friday 7th November 2014

2. COPD Clinical Chairs

K. Finan, Sligo General Hospital, Co Sligo M. Sheehy, Midland Regional Hospital, Mullingar, Co Westmeath

2.1. COPD Outreach—The Patient Perspective A. Lanigan, C. Wynne, E. Kelly Respiratory Department, St Vincent’s University Hospital (SVUH), Dublin Chronic obstructive pulmonary disease (COPD) Outreach reduces reexacerbations, re-admissions and reduces length of stay. Our aim in this project was to ascertain the patient’s perspective of the service in SVUH. We devised two questionnaires which were submitted and passed by Ethics and Clinical Audit committees. Over a 3 month period they were given to the patients at 2 and 6 week reviews and returned anonymously in self addressed envelopes. 35 questionnaires were distributed with a response rate of 88 % at 2 weeks and 53 % at 6 weeks. Questions were categorised into; Quality Improvement, Professionalism, and Accessibility. At 2 weeks all patients were either completely or very satisfied with the care they received, information provided and availability of Outreach staff. The team was described as helpful and friendly. All stated they would rather have been treated at home rather than in hospital. At 6 weeks patients felt that the service had helped them to cope better and feel less breathless. The results show that our patients feel they are receiving safe and optimal care in their home and prefer it to an acute hospital stay.

2.2. The Effectiveness of an Outpatient Multidisciplinary Pulmonary Rehabilitation Programme on Physical Fitness, Psychological Wellbeing and Self-Management of Respiratory Symptoms in Patients with Chronic Obstructive Pulmonary Disease (COPD) C.M. Quinna, M. Dervana, C. McInerneyb, A. O’Brienc, N. O’Sheaa, G. Cartyd, J. Saunderse a

Physiotherapy Department, UL Hospitals—Ennis Hospital, Respiratory Nurse Specialist, UL Hospitals—Ennis Hospital, c Consultant Respiratory Physician, UL Hospitals Group, dPharmacy Department, UL Hospitals – Ennis Hospital, eCSTAR/Statistical Consultant Unit, University of Limerick b

It is predicted that by 2020, COPD will be the 6th leading cause of disability and third most frequent cause of death worldwide. The Global initiative for COPD highlighted the importance of pulmonary rehabilitation in terms of reducing symptoms, improving quality of

S501 life and increasing participation in everyday activities. Therefore a programme based on international guidelines was implemented. Participants with a diagnosis of COPD were eligible to take part in a biweekly 2-h class for 8 weeks containing exercises and multidisciplinary education components. Patients underwent pre and post assessments including subjective measures, shuttle walk tests, muscle strength and spirometry. 38 participants (21 Male), mean age 68 ± 8 years completed the programme. Statistical analysis found significant improvements in all aspects of the Chronic Respiratory Disease Questionnaire including depression (p \ 0.001), fatigue (p \ 0.001), emotion (p = 0.002) and mastery (p = 0.003). COPD Assessment Tool scores reduced (p \ 0.001). Depression reduced significantly (p \ 0.001) based on the Hospital Anxiety and Depression Scale scores. Walking distances increased by 105 ± 61 m (p \ 0.001) and 461 ± 311 m (p \ 0.001) for the incremental and endurance shuttle walk tests respectively and grip strength improved (p \ 0.001). Results demonstrate that 16 sessions of pulmonary rehabilitation significantly improves physical fitness, respiratory and psychological measures. Future analysis should examine long-term maintenance of these benefits.

2.3. Retrospective Comparative Cohort Study of Patients with COPD and Lung Cancer Receiving Specialist Palliative Care N. O’Leary, C. McAleer, G. Tracey Our Lady’s Hospice and Care Services (OLH&CS) Dublin Specialist palliative care (SPC) is of proven benefit for cancer patients. The expansion of SPC for patients with COPD has been recommended. OLH&CS provides SPC for patients with COPD and has tailored its response. Little is known about the effectiveness or adequacy of the SPC response for COPD patients. Aim to compare the needs/patterns of service utilisation of patients with COPD and lung cancer (LC) receiving SPC. Retrospective electronic database and chart review. All consecutive COPD patients referred to OLH&CS over a 12 month period were included. Equivalent number LC patients were randomly sampled. Data was entered into SPSS. 47 COPD patients were identified. COPD cohort was older and more likely to require home oxygen. At initial referral, opioid use was more prevalent in the LC cohort. COPD patients were more likely to have been referred by respiratory teams, to receive targeted therapy for symptoms e.g. breathlessness management, Physio/Occupational therapy input and utilised OPD and Day Hospice services more. COPD cohort was more likely to be discharged, but length of involvement with SPC was significantly longer. The SPC response to COPD patients has evolved and become more tailored. Further research is required to evaluate the effectiveness of the response. References: 1. Department of Health & Children, Report of the National Advisory Committee on Palliative Care (2001) Dublin. (NACPC) 2. National Institute for Health and Clinical Excellence (2011) Services for people with chronic obstructive pulmonary disease. http://www.nice.org.uk/guidance/CMG43/chapter/1-commissioningservices-for-people-with-chronic-obstructive-pulmonary-disease

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2.4. Observational Study of Patients Following an Acute Exacerbation of COPD: Medication Adherence, its Associations and Consequences I. Sulaiman1, J. Seheult1, E. MacHale2, D. Seow1, F. Rawat1, M.A.R. Al Fattani1, N.A. Mat Isa1, W. Paine1, B. Deering3, McCormak3, B. Cushen1, R.W.Costello1 1 Department of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland, 2Respiratory Department, Clinical Research Centre, RCSI, Dublin, Ireland, 3COPD Outreach Department, Beaumont Hospital, Dublin, Ireland

Chronic obstructive pulmonary disease (COPD) remains one of the leading causes of morbidity and mortality worldwide. Inhalation therapy such as dry powder inhaler is one of the commonest medications used by patients with COPD. This is an on-going prospective observational study done in Beaumont Hospital looking at inhaler adherence rates after an acute exacerbation of COPD (AECOPD) and factors that may influence poor adherence. Medical notes of patients admitted were reviewed daily looking for patients admitted with an AECOPD and on a Seretide Diskus TM inhaler. Patients were asked to fill out questionnaires on the CAT, mMRC, EHLS, HADs and MoCA. Patients were then given an INCA enabled inhaler, which they took home with them for a month of use. After a month data from the INCA was collected as well as data on exacerbations, CAT, mMRC and HADs. 70 patients have been approached between February 2012 and July 2014. In the first group of recruits there were 8 device failures, and devices were lost in 16 patients, leaving 45 patients with full data for analysis In this cohort 44 % were male and 56 % were female, while the average age was 57 (37–88). All patients had a history of smoking, while 23 % of patients were current smokers. Pulmonary function tests (PFT) done on the patients showed a mean FEV1 of 1.27 (±0.51) while the cough PEFR average is 174.5L/min (50–300), lower than expected for effective cough clearance. The majority of these patients had a high exacerbation rate, 3.1 in the last year, a high CAT score (21) and a high mMRC score (3.71). Looking at inhaler adherence, the overall attempted adherence rate (where patients try to take their inhaler) was 0.73 (0–1.00) where actual adherence (accounting for technique errors) was significantly lower (p \ 0.001) at 0.29 (0–0.88). The most common technique errors identified were multiple inhalations and poor inspiratory flow rate. Female patients and patients with higher MoCA scores were more likely to have technique errors. In conclusion, the inhaler adherence rate of patients after an AECOPD is very poor. Most common technique errors include multiple inhalations and poor inspiratory flow rate. More work is being done to look at how this impacts on exacerbation rates.

2.5. Admissions to Hospital for Acute Exacerbation of COPD: Is There a Need for a Discharge Bundle?

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 the literature [2]. We reviewed the 1 year AECOPD admissions in one hospital to assess compliance with such interventions. The Hospital Inpatient Enquiry (HIPE) database generated a list of those admitted with a principal diagnosis of AECOPD) between 1st January 2013 and 31st of December 2013 (232). Of 187 located charts, 174 met the diagnosis of AECOPD. Using a pre-piloted questionnaire relevant variables were extracted. Descriptive analysis was performed. Associations between variables were explored using parametric and non-parametric tests (T test, Chi-square, Mann–Whitney). Median age was 73 years. 54 % were males. 56 % were not current smokers. Key results are summarised below.

Intervention documented % Inhaler technique demonstrated

59.2

Written management plan

23.8

Current smokers Assistance offered during admission

42.2

Assistance offered at discharge

62.3

FEV1recorded

57.5

Oxygen assessed Pulmonary rehabilitation referral

86.8 11.1

Follow-up arrangements documented

84.5

Vaccination status documented/discussed Influenza

15.5

Pneumococcal

16.7

Not all patients admitted with AECOPD received key interventions. The introduction of a discharge bundle incorporating same > could impact positively on patients both in this hospital and nationally. References: 1 Crinion S, Cotter O, Kennedy B, Curran DR, McCormack, Mc Donnell TJ, OConnor TM (2013) COPD Exacerbations: a comparison of Irish data with European data from the ERS COPD Audit. IMJ, 106 (9):268–272 2 Hopkinson NS, Englebretsen C, Cooley N, Kennie K, Lim M, Woodcock T, et al (2012) Designing and implementing a COPD discharge care bundle. Thorax, 67(1):90–2

2.6. An Audit of NIV Use for COPD Patients with Acute Hypercapnoeic Respiratory Failure in Hospital In-patients M.C. Mokoka, M.J. McDonnell, L. O’Connor, J. Garvey, A. O’Regan, J.J. Gilmartin Department of Respiratory Medicine, Galway University Hospitals

C. Migone, E. Kelly, M. OConnor, T. McDonnell Department of Respiratory Medicine, SVUH, Department of Public Health HSE East Patients with acute exacerbations of COPD (AECOPD) have frequent hospital readmissions [1]. A discharge bundle could reduce these readmissions. Interventions for such bundles have been identified in

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BTS guidelines recommend the use of non-invasive ventilation (NIV) as a therapeutic trial for treatment of acute exacerbation of COPD (AECOPD). NIV is often considered the ceiling of treatment in patients deemed unsuitable for intubation; such decisions should be clearly documented. Arterial blood gas (ABG) analysis should be performed within 1–2 h of NIV initiation. We sought to determine compliance with these guidelines in Galway University Hospital.

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 An audit of patients with AECOPD and acute hypercapnoeic respiratory failure admitted Nov 2013–Jan 2014 was conducted. 11 patients were identified; 3 (27 %) had an ABG performed within 1 h. Average time to first ABG in remaining 8 patients was 9 h 43 min (range 2–24 h). Documentation regarding escalation of care or ceiling of treatment was recorded in only 27 %. Re-audit in June 2014 identified 10 patients. Of these, an ABG within 1 h of commencing NIV was performed in 50 %; average time to ABG analysis in remaining 50 % was 10.5 h (range 4–22 h). Documentation regarding escalation of care or ceiling of treatment was recorded in 40 %. Initiation and assessment of NIV response in our centre did not meet BTS guidelines. Awareness and compliance with guidelines enables early identification of NIV failure and appropriate treatment adjustment.

2.7. Identifying patients for ambulatory oxygen prescription

S503 A respiratory consultant screens all new patient referrals for suitability. Patients have an assessment which includes history taking, examination, and an education review. Investigations performed include chest X-ray, spirometry with reversibility, BNP, ECG, 6 min walking test and in appropriate circumstances, ABG and alpha 1 antitrypsin deficiency screening. Subsequently, the nurse discusses findings with a respiratory consultant and develops a plan of care. Of the patients (85) reviewed 41 % had COPD, 29 % asthma and the remainder had no significant respiratory problem. Patients experience a faster service appropriate to their needs. Specialist physician review for newly referred patients has now reduced (9 months 2013–6 months 2014). Patients benefited from optimisation of medication, early diagnosis and treatment in a single visit to a clinic. Consequently, multiple outpatient attendances are avoided. This study suggests that nurse led clinics can provide a time and cost saving alternative to the traditional outpatient clinic for patients with respiratory problems. Reference: 1. Davies R (1999) Waiting lists for healthcare: a necessary evil? Canad Med J, 160 (10):1469–1470

M. Okoye, P. Duggan, M.F. O’Driscoll, M. Ward, S.D. Perumal, T.J. McDonnell Department of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin It is known that oxygen prescription to patients with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis (PF) are associated with significant cost and potential morbidity. Although most oxygen prescription abides to BTS and NICE guidelines, there is still a gap in understanding the criteria and patient follow-up for ambulatory oxygen prescription. We investigated the criteria and follow-up for ambulatory oxygen prescription for patients with COPD and PF A retrospective audit was conducted on 30 patients in our Oxygen assessment clinic database. Major outcomes audited include Forced Expiratory Volume in 1 sec (FEV1), Arterial blood gas analysis (ABG) in room air and 6 min walk test (6MWT). From the audit, we identified all 30 patients had a new prescription for ambulatory oxygen. Of those 30 patients (mean FEV1 = 46.4 %), 10 were on LTOT prior to the new ambulatory prescription. The new prescription was mostly based on the 6 min walk on their clinic visit. The mean ambulatory prescription was 3 L per min via nasal prongs. This audit reveals that guidelines were largely followed on ambulatory oxygen prescription. However, the audit re-enforces the need for the repeat ABG on the return visit to review their current baseline oxygen needs and patient education on oxygen therapy. Further this audit also enlightens the view on timely follow on LTOT patients as their needs may have change at a time frame of 3 months or 90 days from the initial prescription.

2.9. Is there any Correlation Between the Classification of COPD Severity by GOLD 1234 Grades and GOLD ABCD Groups? S. Yambasu1, R. Cusack2, S.J. Lane2, R. Hawksworth1 1 School of Medicine, Trinity College, Dublin, 2Department of Respiratory Medicine, Adelaide and Meath Hospital, Dublin

To classify patients under both the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1234 guidelines (2001) and the GOLD ABCD guidelines (2011) to see if there is any correlation between the classification of severity by these guidelines. Adult outpatients with a clinical diagnosis of COPD were recruited from those attending outpatient respiratory clinics. Spirometry data was obtained and then a questionnaire was carried out to collect information on severity of symptoms and rate of exacerbations. This information was used to grade patients according to the original GOLD 1234 guidelines and the updated GOLD ABCD guidelines. Classification of subjects according to each guideline was compared. 29 patients entered the study. They were categorised as GOLD I (n = 10), GOLD II (n = 13), GOLD III (n = 6) and GOLD IV (n = 0). When graded according to the new GOLD guidelines, the patients were separated into GOLD A (n = 6), GOLD B (n = 3), GOLD C (n = 7) and GOLD D (n = 13). Two patients were downgraded, ten patients remained the same and 17 patients were upgraded. The study concluded that the new COPD guidelines are more reflective of the reality of disease burden, and results in enhanced pharmacologic interventions, in this group of patients.

2.8. The Development of a Rapid Access Respiratory Nurse Led Clinic P. O’Toole, Ward Mary, A. Deegan, T.J. Mc Donnell Department of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin

2.10. A Survey of Lung Health and COPD Awareness amongst Participants at a Mobile Spirometry Clinic R. Rajgopal1, C. Migone2, D. Peelo3 University of California, Berkeley, 2Department of Public Health, HSE-East. 3COPD Support Ireland

1

Patients referred by their GP with new respiratory problems endure a long wait for a specialist respiratory review. This may have a detrimental effect on morbidity and mortality [1]. To address this issue, a nurse led clinic was introduced in November 2013.

Chronic obstructive pulmonary disease (COPD) is a leading cause of death in Ireland. It may affect over 440,000 people (10 % of the

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S504 population) in Ireland1. Furthermore, awareness of COPD may be low. COPD Support Ireland is Ireland’s first charity set-up to support and advocate for those living with COPD. For World COPD Day 2013, a mobile clinic traveled to various locations (5) around the country to provide public information about COPD and free Spirometry testing. Participants completed a questionnaire of their demographic details and risk factors for COPD, prior to Spirometry testing (n = 352). Those with abnormal Spirometry were referred (n = 63) to their GP. Questionnaires were analyzed to ascertain this self-presenting population’s characteristics including those of the referred group. Around 70 % of the participant population were smokers/ex-smokers, yet\50 % knew about COPD prior to the event. Approximately one in five people was referred on to see a GP after our event. The findings of this study suggest the need for greater COPD education and awareness to increase diagnosis rates and improve the quality of life for those who suffer from this disease. With these improvements, there is a greater potential for economic gain2 and better overall health. References: 1. National Respiratory (COPD) Framework (2008) Irish Thoracic Society, Health Service Executive, Irish College of General Practitioners 2. Tynan AJ, Lane S (2005) COPD Illness severity, resource utilisation and cost. Irish Med J, 98(2):4

2.11. New Modified Exercise Regime to Promote Physical Activity in COPD S.D. Perumal, M. Okoye, T.J. Mc Donnell Department of Respiratory Medicine and Physiotherapy, St.Michaels Hospital, Dun-Laoghaire Exercise training is the cornerstone of pulmonary rehabilitation (PR). However, there is no consensus on an exercise regime to promote physical activity in patients with COPD. We investigated the effectiveness of new modified exercise regime in PR. The secondary objective was to evaluate whether this regime promotes physical activity (PA) in patients with COPD. Retrospective analysis was performed on data from 29 COPD patients [FEV1: 59.08 (22.00) %] who completed an 8 weeks outpatients PR programme. All patients received 30 min supervised exercise training and 1 h of self management education for 3 sessions per week. A baseline walking prescription of 80 % average of their initial 6MWT for 4–5 days per week in patient activity log (PAL) sheet was provided. Outcome measures include 6MWT, ISWT, CAT score, CRDQ and PAL were used to quantify exercise capacity, quality of life and PA. Paired t test, Spearman correlation and linear regression were used to examine possible associations between physical activity, exercise capacity and quality of life. Significant improvement was noted in all outcome measures compared to baseline. Good correlation was found between physical activity and exercise capacity compared to quality of life.

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 This exercise regime comprising 30 min structured exercise session and a walking prescription promotes physical activity in patients with COPD.

Parameters

Pre-rehab [mean (SD)]

Post-rehab [mean (SD)]

P value

6MWT (m)

385.5 (65.2)

472.1 (73.9)

\0.0001

ISWT (m)

335.5 (146.0)

399.7 (134.8)

0.0081

PA (min)

14.1 (3.0)

20.69 (7.9)

\0.0001

CAT score (points)

23.6 (6.1)

18.90 (7.9)

0.0017

CRDQ (points)

13.0 (3.6)

17.70 (2.7)

0.0002

References: 1. Lacasse Y, Martin S, Lasserson TJ, Goldstein RS (2007) Metaanalysis of respiratory rehabilitation in chronic obstructive pulmonary disease. A cochrane systematic review. Eura Medicophys, 43(4):475–485 2. Cindy Ng LW, Mackney J, Jenkins S, Hill K (2012) Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chron Respir Dis, 9(1):17–26

2.12. Emergency Oxygen Therapy in Cork University Hospital S. Healy1, G. Castles1, S. Dunne1, M. O’Grady1, A.M. Fitzgerald1, D. Murphy2, M. Henry2 Physiotherapy Department1, Respiratory Department2, Cork University Hospital The British Thoracic Society (BTS) published a guideline on emergency oxygen use in 2008 [1]. The Physiotherapy Department in Cork University Hospital (CUH) carried out a one-day audit in November 2013, endorsed by the Respiratory Consultants, to evaluate compliance with this guideline with a particular interest in COPD patients. Data was collected using an audit form designed by CUH Physiotherapists which was based on the BTS form. The BTS guidelines were used to determine target oxygen ranges. Palliative patients, those with a tracheostomy and Intensive Care patients were excluded. Results were analysed using Microsoft Excel. 55 patients (12 %) were on oxygen and one-third of these had a documented history of COPD. This compared to 13.8 % of patients on oxygen in the BTS Audit [2]. Of these 55 patients, 42 (76 %) were in the correct target SpO2 range compared to 57 % in the BTS audit [3]. Table 1: Percentage of patients outside the target SpO2 range compared to the BTS audit [3]

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

Below SpO2 target range

S505

Above target range

2.14. A Descriptive Study of Chronic Obstructive Pulmonary Disease Patients

CUH (%) BTS audit (%) CUH (%) BTS audit (%) Non COPD 3.6 COPD

1.8

Total

5.4

W.L. Ng, A.L. Carneiro, G. Giblin, A. O’ Brien

5.5 12.6 9

18.1

22

Patients outside the target SpO2 range were mostly above the target and two-thirds of these were COPD patients. Target ranges should be prescribed for all patients, especially those with a documented history of COPD. References: 1. O’Driscoll BR, Howard, LS, Davison AG (2008) BTS guideline for emergency oxygen use in adult patients. Thorax, 63(Suppl VI):vi1– vi68 2. O’Driscoll BR, British Thoracic Society Emergency Oxygen Audit 2013 [Internet]. 2014 [cited 2014 August 14th]. https://www. brit-thoracic.org.uk/document-library/audit-and-quality-improvement/ audit-reports/bts-emergency-oxygen-audit-report-2013/ 3. O’Driscoll BR. Emergency Oxygen use in UK Hospitals—BTS Hospital Oxygen Audits 2008-2012 [Internet]. (undated). [cited 2013 March 14th]. http://www.brit-thoracic.org.uk/Portals/0/Audit%20 Tools/BTS%20Oxygen%20Audits%202008-2012.ppt

Department of Respiratory Medicine, University Hospital Limerick, Dooradoyle, Limerick Chronic obstructive pulmonary disease (COPD) poses great impact on patient’s quality of life. This study aims to view the management of COPD patients. Data of 113 patients admitted with acute exacerbation of COPD in 2013 was collected. 101 who were not deceased or transferred to other hospitals were included in the study. Statistics show that 69 (68.3 %) were aged B75 years. 45 (44.6 %) were males and 56 (55.4 %) were females. 33 (32.7 %) are smokers and 45 (44.6 %) were ex-smokers. Arterial blood gas (ABG) was performed on 66 (65.3 %) patients. 91 (90.1 %) were on antibiotics, 79 (78.2 %) on oxygen and 92 (91.1 %) on nebuliser. 30 (29.7 %) were cared for by respiratory physician and 21 (20.8 %) were reviewed by respiratory nurse. 24 (23.8 %) were discharged on inhaler only, 13 (12.9 %) with nebuliser only and 48 (47.5 %) with both.

2.13. Management of Acute COPD Exacerbations in St Michael’s Hospital. A Retrospective Data Analysis carried out in Conjunction with the European Pathway Association S.C. Carter, P. Doyle, I. Callanan, T.J. Mc Donnell St Michael’s Hospital, Dublin and European Pathway Association, Leuven, Belgium COPD exacerbations are a major cause of morbidity and mortality across Europe. The European Quality of Care Pathway (EQCP) Study is a cluster randomised control trial of COPD exacerbations in Belgium, Italy, Ireland and Portugal. It aims to evaluate the impact of a care pathway on teamwork, process and outcome indicators. Prior to implementing a pathway a baseline assessment was conducted to assess standards. As part of this process we measured adherence to such standards in our hospital. A retrospective data analysis of 20 consecutive COPD admissions of [48 h duration was carried out. Patients were cared for on a ward where COPD patients are usually managed and none required invasive ventilation. Initial appropriate investigations were performed in a timely manner in most cases. Appropriate medication prescribing, assessment of nutritional status and educational interventions were areas of weakness. The information collected highlighted the need for intervention. A care bundle for the acute management of COPD exacerbations is used in our institution and has had an impact on the appropriate initial management of COPD exacerbations. However, appropriate prescribing and planning for medium and long-term management of COPD exacerbations remains suboptimal, identifying an area where future interventions may prove beneficial. References: GOLD Guidelines. Published online [cited 10th August 2014]. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosismanagement.html

This study shows a majority of COPD patients were aged B75 with a preponderance of females. Antibiotics and oxygen were widely prescribed. However, the management of COPD patients was far from satisfactory as a third are still smoking, a third had no ABG done and a large number were discharged on nebulisers. Only 20.8 % were seen by respiratory nurse and 29.7 % by respiratory physicians.

2.15. The Use of Nebuliser in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) W.L. Ng, A.L. Carneiro, G. Giblin, A. O’ Brien Department of Respiratory Medicine, University Hospital Limerick, Dooradoyle, Limerick The use of nebulised therapy is often the standard care for acute exacerbation of chronic obstructive pulmonary disease (COPD). However, inappropriate use of nebulisers is commonly practiced. We

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S506 performed an audit of the use of nebulisers during acute exacerbations of COPD at our hospital. A retrospective review of 113 patients who were admitted in 2013 was conducted. 12 who were deceased or transferred to other hospitals were excluded. All patients treated with nebulisers were maintained on it throughout hospitalisation. 48 (67.61 %) patients cared for by nonrespiratory physicians were discharged on nebulisers as compared to 14 (46.67 %) patients by respiratory physicians. 16 (22.5 %) patients of non-respiratory physicians were newly commenced with nebulisers on discharge; as compared to 2 (6.7 %) by respiratory physicians. 53 of 80 (66.25 %) not seen by respiratory nurse were discharged on nebulisers versus 9 of 21 (42.86 %) seen by respiratory nurse.

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 CAT improved from mean 19.3 to 13.5. Mortality was 4.9 % among Outreach patients and 2.5 % for overall AECOPD in 2012–2013. COPD Outreach reduced ALOS and improved HRQoL for selected patients with AECOPD. It did not reduce re-admissions or improve mortality.

2.17. Inappropriate Prescription of Inhaled Corticosteroids in Stable COPD Patients A. Sahadevan, E. Amoran, A. Rovenco, B. Mahon, R. Aslam, E. Moloney, S. Lane Respiratory Department, Tallaght AMNCH, Dublin Global initiative for chronic obstructive lung disease (GOLD) has provided guidelines for management of COPD. Long term treatment with inhaled corticosteroids (ICS) should only be used for COPD grade GOLD C and D patients. Prolonged use of ICS carries a risk of pneumonia and increased risk of fractures. Our aim was to assess compliance with GOLD guidelines for ICS pharmacotherapy in COPD. Stable respiratory patients with a previous diagnosis of COPD attending the respiratory clinic had their COPD graded using GOLD criteria and their pharmacotherapy reviewed on 2 separate time periods [Feb–March 2014, July–August 2014].

A majority of patients were discharged with nebulisers despite most guidelines including NICE, recommending nebulisers should only be commenced in patients who despite maximal therapeutic intervention did not show adequate response [1]. This audit also highlighted that if cared for by respiratory physicians or reviewed by respiratory nurse, patients were less likely to be discharged on nebulised medication. Reference: 1 National Institute for Health and Care Excellence (NICE) (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). London

2.16. The Efficacy of COPD Outreach in Reducing Length of Stay, Readmissions and Improving Quality of Life A. Sahadevan, C. Baily, L. Cullen, D. Watchorn, M. Kooblall, S. Lane, E. Moloney Department of Respiratory Medicine. Adelaide and Meath Hospital, incorporating the National Children Hospital, Dublin, Ireland COPD results in prolonged hospitalisation, re-admissions, reduces health-related quality of life (HRQoL) and increases mortality. The study aimed to assess the efficacy of a COPD Outreach service in reducing average length of stay (ALOS), reducing re-admissions within 90 days of admission, improving HRQoL and reducing mortality among COPD patients with acute exacerbations (AECOPD). AECOPD data for a 2 year period commencing September 2011 was analysed. The COPD Assessment test (CAT) quantified HRQoL at enrolment and 6 weeks post Outreach. COPD Outreach had ALOS of 2.47 days compared to ALOS 8.59 days and 8.5 days for all AECOPD before and during an operational COPD Outreach. Re-admission rates among patients were 36.3 %.

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GOLD grade

Total

Total patients on inappropriate ICS therapy

Total patients whose inhalers were rationalised/changed according to GOLD recommendations

A

28

9 [32 %]

9

B C

8 5

4 [50 %] 0

4 3

D

18

0

3

All grades

59

13 [22 %]

19 [32 %]

Inhaled corticosteroids are being prescribed unnecessarily in GOLD A and GOLD B COPD patients. Single or dual bronchodilation without using ICS therapy should be sufficient for low risk COPD patients. Rational prescribing using evidence-based GOLD guidelines will help reduce adverse side effects to patients. Furthermore this will cut down overall cost to both patient and the healthcare system. Reference: 1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global initiative for Chronic Obstructive Lung Disease (GOLD) Updated in Jan 2014. www.goldcopd.org/

2.18. Real-Life Experience with Roflumilast Therapy in COPD Patients at Cork University Hospital E. Worndl1, E.B. Hunt1,2, M.K. Kennedy1,2, B.J. Plant1,2, M.T. Henry1,2, D.M. Murphy1,2 Cork University Hospital/University College Cork, Cork1, HRB Clinical Research Facility, University College Cork, Cork2 Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. The PDE4 inhibitor roflumilast has

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 demonstrated clinical efficacy in patients with severe COPD with recurrent exacerbations and has recently been included as part of third line therapy in the GOLD guidelines. This study aimed to identify a population of patients who received roflumilast as part of therapy and to document efficacy with particular reference to the adverse events experienced, the discontinuation rate, and perceived clinical benefit to treatment. A retrospective audit of patients who received therapy at Cork University Hospital between June 2010 and October 2013 was conducted. 25 patients were prescribed roflumilast, with 84 % discontinuing treatment after a mean of 3.5 months. The most cited reason for stopping treatment was intolerance to side effects (81 %), followed by a lack of clinical benefit (19 %). Side effects were experienced by 72 % of all patients, with nausea (52 %), diarrhoea (16 %) and vomiting (12 %) the most common. Improvement in respiratory status was appreciated in 20 % of patients. Our findings suggest that roflumilast has a high side effect burden causing discontinuation of therapy amongst a majority of patients. However, there may be a role for the drug in a subset of patients.

2.19. Spirometry Certificate for Healthcare Professionals—Update G. Nolan1, O. Farrelly2, A. Mc Gowan3, S. Daly4 1

Pulmonary Laboratory, St Vincent’s University Hospital, Dublin, Pulmonary Function and Sleep Laboratory, Midland Regional Hospital, Mullingar, 3Respiratory and Sleep Diagnostics, Connolly Hospital, Dublin, 4Department of Physics, Dublin Institute Technology, Kevin St, Dublin

2

There is increasing global awareness of spirometry as an essential tool for diagnosing and monitoring Asthma and COPD. The Irish Association of Respiratory Scientists (IARS) in partnership with Dublin Institute of Technology (DIT) provides a certified training programme leading to the award of CPD Certificate in Spirometry for Healthcare Professionals. The aim of this programme is to equip healthcare professionals with the technical, practical and clinical skills required to perform good quality spriometry. It is supported by the National COPD and Asthma Clinical Care Programmes and endorsed by the ITS. 370 participants have completed Module 1, a 1-day introduction to spirometry, covering theory and practical knowledge of equipment and performance. Most attendees agreed that they were more confident about performing accurate spirometry after completing this day. Module 2 is a self-directed process of learning over 6–12 months culminating in the practical assessment of spirometry performance according to the ERS/ATS 2005 guidelines [1]. Twenty-one candidates have successfully been awarded the Certificate by DIT since January 2012. There are currently a further eleven in progress. Despite the small numbers graduating, this programme has been very successful to date. The IARS urge all relevant healthcare professionals to obtain full certification in line with international best practice recommendations. Reference: 1. ATS-ERS Taskforce (2005) Standardization of spirometry. ERJ 29:319–338

S507

2.20. Analysis of Acute Non Invasive Ventilation Use in University Hospital Limerick G. Giblin, T. Hynes, T.K. Teoh, H. Song, C. Weldrick, R. Aziz, A. O’Brien Department of Respiratory Medicine, University Hospital Limerick The aim of this study was to evaluate the treatment outcomes, mortality and adherence to BTS guidelines for NIV use in the acute setting in an Irish tertiary referral hospital. A retrospective chart review was performed of all patients commenced on NIV in the ED between January 2013 and March 2014. Data gathered was compared with the national UK audit published annually by the British Thoracic Society. Fifty-six charts were reviewed during this study with 14 patients on home NIV excluded (n = 44, mean age 71.32 years). COPD was the most frequent diagnosis requiring NIV therapy (70 %). 65.9 % had reported consolidation on initial chest X-ray. 45 % of patients had an escalation plan recorded in the event that NIV should fail while 38.6 % had a DNAR status recorded. The mean pH at initiation of treatment was 7.21 (range 7.078–7.52) with a mean PCO2 of 11.06 (range 6.05–20.3). The success group had an initial mean pH of 7.23 in comparison with the failure group (7.16); p = 0.2. 63.6 % had an ABG performed 1–2 h after starting treatment as recommended by the guidelines1 while 46.3 % had a further ABG at 4–6 h. pH had resolved to [7.3 within 4–6 h in 38.6 %. The mean initial pressure settings used were 12/6. (Range IPAP 10–20, EPAP 4–10). NIV was successful in 28/44 (63.6 %), defined as achieving a pH [ 7.3. 3 patients proceeded to invasive ventilation while two patients were discontinued due to intolerance. Following acute NIV treatment, 56.8 % were discharged from hospital without home NIV. The in hospital mortality rate was 38.6%. Mortality was higher in those with an initial PH \ 7.25 than with a PH [ 7.25 (20.45 vs/ 18.18 %). Those with consolidation on their CXR had a higher mortality rate than those without (44.8 vs. 26.6 %). Our study shows that our treatment outcomes and mortality are similar to the BTS UK figures. Significantly increased mortality was noted in patients with pH values \7.25 at presentation and in those with consolidation on CXR. These markers should be used to prioritise the care of these patients in critical care units.

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S508

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

Irish Thoracic Society Poster Review and Discussion Friday 7th November 2014

3. General Respiratory Chairs

V. Keatings, Letterkenny General Hospital, Letterkenny, Co Donegal M. Rogan, University Hospital Waterford, Co Waterford

3.1. How Confident Are Medical Registrars in Performing Respiratory Orientated Procedural Skills?

resulting in safe patient care. Crew resource management (CRM) is one of the best-established approaches to developing NTS in healthcare. CRM uses team-based simulation to improve team working and reduce error. Our aim was to design a NTS educational course for respiratory teams to improve the management of acutely ill respiratory patients. A questionnaire asking medical registrars (n = 24) to rank their comfort levels in the management of 7 respiratory emergencies and their educational requirements was used to develop training objectives for the course. A 1-day course using team-based hi fidelity manikin-based simulation for 8 respiratory registrars, 2 respiratory nurses and 2 respiratory physiotherapists was designed around 4 common respiratory emergencies. Pre-course learning material, scenario templates and assessment tools were developed at a total cost of €1,050. There are no team-based NTS education programmes for medical trainees in Ireland. We have developed a ready-to-use series of NTSfocused scenarios based on real trainee requirements that can be delivered using manikin-based simulation.

A. Scott, D. Byrne, J.F. Garvey, A. O’Regan

3.3. Irish Farmer’s Demographics and Lung Health Department of Respiratory Medicine, Galway University Hospitals, Galway Procedural skills form part of a physician’s armamentarium and require an amalgam of psychomotor skills, clinical judgement, communication, decision making and patient focused interaction (1). The lack of these skills has implications for patient safety and quality of care in particular in the emergency setting. The aim of the study was to identify how confident medical registrars are in performing respiratory orientated procedural skills required for the management of common respiratory emergenices. A procedural skills audit was performed which asked medical registrars (n = 23) with an average of 3 years training post internship to rate their confidence level in performing these skills and whether additional training was required. The results showed that the registrars were least confident in: inserting a chest drain (79 %), administering thrombolysis (75 %), needle thoracocentesis (48 %), setting up NIV (33 %) and managing an airway (21 %) and a large proportion ([70 %) would like further training in these skills. Not all medical registrars have been sufficiently trained in these skills to allow them to perform in a safe and efficient manner in respiratory emergencies. Simulated task based training, repetitive practice and assessment are required for patient safety and should form part of every registrars’ training programme. Reference: 1. Kneebone R, Bello F, Nestel D (2007) Training and assessment of procedural skills in context using an integrated procedural performance instrument (IPPI). Stud Health Technol Inform 125:229–231

3.2. A New Team Based Non-Technical Skills Educational Course to Improve the Assessment and Management of Acutely Ill Respiratory Patients

N. Donoghue2, D. Langan1, B. Cushen1, T. Cahill1, E. Nic Dhonnacha1, O. Healy1, F. Keegan1, M. Browne3, I. Sulaiman4, A. O’Regan1 1

Department of Respiratory Medicine, Galway University Hospital, Department of Respiratory Medicine, Bon Secours Hospital, Galway, 3NUI Galway, 4 Royal College of Surgeons in Ireland

2

Recent studies have demonstrated that Irish farmers have a shorter life expectancy compared to other professions. This is in part accounted for by accidents and cardiovascular disease. Little is known about the prevalence of respiratory disease and access to health checks in this population. We undertook a cross-sectional assessment of farmer’s lung health at the 2013 Ploughing Championships. Baseline demographics, selfreported respiratory disease, and usage of health services was recorded. Data from 381 farming volunteers was suitable for analysis. Farmers had a very high BMI, median 29 kg/m2 with 44 % obese, BMI [ 30 kg/m2. Only 9 % were current smokers with 60 % never smokers. 10 % had a past history of Asthma, 1 % COPD and 10 % use inhalers. Surprisingly only 0.5 % had a prior diagnosis of farmers lung. 11 % reported 2 or more chest infections per year. 1 in 5 with chest infections did not seek medical attention with only 29 % attending their GP in the last year. The prevalence of smoking in farmers is low with prior diagnosed lung disease similar to national averages. Obesity is prevalent and farmers rarely engage in health checks. This likely reflects a tendency to over-estimate their general health combined with reduced accessibility to healthcare.

3.4. Profile of Beaumont Physiotherapy Critical Care Service

A Scott, J.F. Garvey, A. O’Regan, D. Byrne Catrı´ona Nı´ Chearbhaill1, Pedro Vasquez1, James O’Rourke2 Department of Respiratory Medicine, Galway University Hospitals, Galway

1

Physiotherapy Department, Beaumont Hospital, Dublin, Department of Anaesthesia, Beaumont Hospital, Dublin

2

Failures in nontechnical skills (NTS) are the most frequent contributing factors to poor performance in emergency medical care. NTS are a combination of cognitive (decision making) and social skills (communication) that complement knowledge and technical skills

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Best practice guidelines recommend that rehabilitation of critical ill patients should be led by healthcare professionals with adequate competencies [1].

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 In January 2013 the Beaumont Physiotherapy Critical Care Team was established with the aim of providing a more efficient, flexible and reliable service for critical care patients. A retrospective statistical review of 6 months of the physiotherapy critical care service was carried out. This data was compared to statistics from the first 6 months of the previous year. In addition a satisfaction questionnaire was carried out to gain feedback from members of the multidisciplinary team. Information gathered included ratings on the flexibility and quality of the service, availability and reliability. Results: Physiotherapy interventions per whole time equivalent increased by approximately 200 in the first 6 months of the new service. An increase in treatment times of 5 min from 30 to 35 min per patient was maintained from the previous year. Satisfaction Questionnaire: 5= Excellent, 1= Poor.

5 4 3

S509 Table 1: results of survey Yes

No

Yes (%)

No (%)

Use of closed suction routinely

6

4

60

40

Use of protective equipment with yankeur suction routinely Use of protective equipment with oropharyngeal suction routinely

0

10

0

100

0

10

0

100

0

10

0

100

Use of protective equipment with tracheal suction routinely

3.6. Respiratory Medicine On-call: an Analysis of Referrals to this New Service P. Eoin Judge, David Watchorn, Diarmuid Cadogan, Chika Offiah, Kate Hunter, Liam Power, Ruairi Fahy, Judith Lyons, Ann-Marie McLaughlin, Rory O’Donnell, Finbar O’Connell

2 1 0 Flexibility of service

Reliability

Quality of Availability service

Figure 1: Results of Staff Satisfaction Questionnaire Results suggest a more efficiency service with patients continuing to experience longer treatment sessions. Feedback for the questionnaire demonstrates that overall the service is of high standard and highlighted areas for further development. Reference: 1. NICE Guidelines for Rehabilitation after Critical Illness (2009)

3.5. A National Survey of Physiotherapy Use of Personal Protective Equipment during Suctioning and Development of Beaumont Physiotherapy Guidelines C. Nı´ Chearbhaill1, N. Cunneen1, P. Vasquez1 1

Physiotherapy Department, Beaumont Hospital, Dublin

Personal protective equipment (PPE) is an important safety precaution in the management of many respiratory patients [1]. The objective of this survey was to establish national physiotherapy use of PPE when carrying out various suctioning techniques. For the purpose of this survey PPE refers to the use of standard equipment to include goggles and facemask protection. The survey was distributed to senior physiotherapists in all Health Service Executive (HSE) hospitals with an intensive care unit. Eleven physiotherapists responded to the survey. Data regarding personal protective equipment use was obtained. The use of closed suction was included in the survey due to the risk of cross contamination in mechanically ventilated patients. This survey highlights that the use of full personal protective equipment amongst physiotherapists in Ireland is poor. Local PPE guidelines were developed to promote the use of PPE within the Beaumont physiotherapy department. Reference: 1. NICE Guidelines March (2012) Infection: prevention and control of healthcare associated infections in primary and community care

Department of Respiratory Medicine, St. James’s Hospital, Dublin 8, Ireland A new, 7 days per week, specialist respiratory medicine on-call service commenced in St. James’s Hospital in July 2014. The aim is to provide targeted inpatient specialist care for patients presenting with acute respiratory illness in the hope of optimising their outcomes. The current study evaluates the volume, type and accuracy of referrals to this service. Patient demographic data and information regarding individual referrals received for the first 60 referrals (including referral source, presenting symptoms, accuracy of the referring diagnosis, deaths) was collected daily and recorded as part of an ongoing audit process. The median age of patients referred was 68 years. Dyspnoea (78 %) and cough (77 %) were the commonest presenting symptoms. The most common diagnoses were exacerbation of COPD (27 %), pneumonia (22 %) and lung cancer (15 %). Most referrals (63 %) were from the general medical on-call team, and 22 % were direct referrals from the emergency department. The referral diagnosis was accurate in 90 % of cases. The median length of inpatient stay was 5 days. Four patients died over the follow-up period. Referrals to the respiratory medicine on-call service in our hospital are appropriate and cover a broad spectrum of respiratory disease.

3.7. The Management of Tracheostomy Patients in Cork University Hospital (CUH) over a 7 year period Authors: Maeve O’Grady1, Aideen O’Riordan2, Siobhan Healy1 Physiotherapy Department1, Speech and Language Therapy Department2, Cork University Hospital The purpose of the study is to gather the following information on tracheostomy patients in CUH from 2007 to present. 1. 2. 3. 4.

Number of cannulations per discipline Length of cannulation Outcome Percentage of deaths for each discipline per year

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5. Identify areas requiring increased resource allocation. 6. Highlight service initiatives that have been developed in response to findings Data is collected on weekly ward rounds and results are presented annually to the multidisciplinary team. Population included every patient in CUH with a tracheostomy. The number of tracheostomy patients has fallen by[50 %, despite increased acuity and complexity of patients. The largest decrease was seen in surgical (cardiothoracic and general) patients, from 23 in 2007 to 7 in 2013. Number of new patients per discipline Discipline:

2007 2008 2009 2010 2011 2012 2013

Neurosurgery Cardiothoracics

6 14

11 9

11 8

15 8

10 6

7 9

4 6

Neurology

3

9

3

5

1

0

3

Vascular/general surgery

9

6

2

3

3

1

1

Renal

2

5

3

4

2

3

1

Respiratory

3

2

5

5

6

7

0

Haematology

0

2

0

1

0

0

0

Rheumatology

0

2

0

0

1

2

0

Plastics

3

2

1

1

2

2

0

Endocrinology/ general med/ gastroenterology

2

3

1

1

0

1

0

Infectious diseases

0

1

1

2

0

1

0

Oncology/radiotherapy 2

0

3

1

0

1

1

Cardiology

0

0

2

0

0

0

0

Orthopaedics

0

0

1

1

1

0

3

Elderly medicine

0

0

0

0

1

0

1

This data highlights the positive changes in the tracheostomy service in CUH which are a result of an effective multidisciplinary tracheostomy team, established in 2005. It has identified that having a core group of clinicians with specialist knowledge in the management of tracheostomy patients improves patient management, including decision making regarding appropriate patient selection. It highlights areas that have needed increased resources, resulting in service development specific to need, including education and increased service provision in identified clinical areas.

3.8. Does Age of the Patients Influence the Pain Threshold Post VATS Procedures? M. Tarazi, M.N. Anjum, M. Anwer, K. Doddakula

for pain scoring. Pain severity was assessed during immediate postop inpatient period and post discharge. Our results showed that older patients had a better tolerance of pain during the initial post op phase and during chronic phase.

3.9. Smoking Prevalence and Awareness of Smoking Cessation Services among Health Service Staff ´ hAiseadha1, M. Killeen2, F. Howell3, Jean Saunders4 C. O Department, Institution and City/Town: 1Department of Public Health, Health Service Executive (HSE), Dublin, 2National Tobacco Control Office, HSE, Naas, 3Department of Health, Dublin, 4 Statistical Consulting Unit, University of Limerick, Limerick

3.10. The Delivery of Smoking Cessation Advice to Hospitalised Smokers: A Two-Hospital Survey L. Mellon1, N.G. McElvaney2, L. Cormican3, R. Conroy1, A. Hickey1, H. McGee4, R. McDonnell5, Frank Doyle1 1 Division of Population Health Sciences, Royal College of Surgeons in Ireland (RCSI), 2Professor of Medicine, RCSI; Consultant Physician, Pulmonary Division, Department of Medicine, Beaumont Hospital, 3Consultant Respiratory Physician and Honorary, Clinical Senior Lecturer (University College Dublin & RCSI), 4Dean, Faculty of Medicine and Health Sciences, RCSI, 5Post-doctoral Researcher, HRB Centre for Primary Care Research, RCSI

Brief smoking cessation advice from healthcare professionals increases quit rates among hospitalised smokers. However, little is known about the extent inpatients receive such advice. We profiled smokers and the provision of cessation advice received by in-patients in two teaching hospitals, with subsequent 3-month quit rates. We surveyed 1,001 in-patients across Beaumont and Connolly hospitals over 6 months. Data was collected on record of smoking status, delivery of smoking cessation advice, Fagerstrom Test for Nicotine Dependence and attitudes towards smoking cessation. Quit rates at three months post-hospitalisation are currently being ascertained. Prevalence of smoking was 23.2 % (232/1001). Only 31.5 % of smokers (n = 76) reported that smoking cessation was discussed with them during admission, while 20.7 % (n = 50) reported that they would like to receive such advice. Smoking status of the patient was documented for 58 % (n = 128) of patients, however delivery of cessation advice was documented in only 2 % (n = 5) of cases. Smokers’ mean Fagerstrom nicotine dependence score was 3.7 (SD = 2.7), indicating low dependence levels Provision of cessation advice is suboptimal. As average dependence scores are low, this suggests that low-intensity interventions would be beneficial for most smokers. A strong, systematic focus on provision of brief smoking cessation advice is needed in hospital settings.

Cardiothoracic Surgery, Cork University Hospital, Ireland Pain following video assisted thoracic surgery is a major concern and has huge economical implication. We tried to evaluate if age of patient plays a vital role in their pain tolerance. We retrospectively studied all VATS patients from April 2012 to March 2014. Patients were subdivided into groups as follows, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79. Visual analogue pain scoring was used for pain assessment. Patients were to fill the form or a telephonic interview was performed

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3.11. Use of Ecigs in Irish School Goers K. Babineau, S. Keogan, L. Clancy TobaccoFree Research Institute Ireland, DIT Focas Institute, Camden Row, Dublin 8 The use and regulation of e-cigarettes is a controversial issue, particularly as they become more ubiquitous. There are potential benefits

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for individual smokers to reduce the physical harm and the chance to try an alternative method of quitting, the efficacy of using e-cigarettes as a cessation aid is not yet clear. Young people in their 5th year of secondary school, aged 16–17, were chosen as the target population. A representative sample of secondary schools from around the country was selected for participation. Fifth year students from 16 secondary schools across Ireland were selected for participation in the study. A sample of 901 young people from 16 secondary schools were administered a questionnaire. The average age of participants was 16.6 years old. There was a near equal gender divide, with 49.3 % male and 50.7 % female. Frequencies were calculated for e-cigarette use for all participants and v2 were performed to examine significant differences between sub-groups in the sample. 77.4 % of regular tobacco smokers have tried e-cigarettes. Of ‘ever-smokers’, that figure drops to 32.2 %. Among never smokers, the proportion is 4.2 % (Table). This report does provide solid, representative data about current e-cigarette use among young people under the age of 18 in Ireland. Table E-cigarette use among young people, arranged by tobacco smoking status (N %) Never tobacco

Ever

smokers

smokers

tobacco

Regular tobacco smokers

Referrals to cessation services by Healthcare Professional's 35.0%

31.8%

30.0% 25.0%

22.0%

20.0% 15.0% 10.0% 5.6%

5.0% 0.0% Nurses

Doctors

Dentists

Total

(at least once a week) 26 (22.6)

should routinely advise patients to quit smoking compared to the current and ex-smokers (91.8 %). 67.3 % Dentists, 80 % Nurse and 84 % Doctors felt they were regarded as role models by the public and their patients, to function as such HCPs need to stop smoking and be confident in their knowledge of how best to treat smokers, despite this only 22 % of HCP’s referred smokers to Smoking Cessation Services.

3. 13. Characteristics of Smoking Behaviour in Patients Post Curative Resection of Stage 1 Lung Cancer

Never E-cig 414 (95.8) users

187 (67.8)

627 (76.2)

Ever E-cig users

16 (3.7)

82 (29.7)

78 (67.8)

176 (21.4)

Regular E-Cig users

2 (0.5)

7 (2.5)

11 (9.6)

20 (2.4)

Total

432 (100.0 %) 276 (100 %) 115 (100 %)

R.J. Smyth, J. Lyons, C. Comerford, F. O’Connell Respiratory Department, St. James’s Hospital, Dublin

823 (100 %)

3. 12. Role of Healthcare Professionals in Smoking Cessation

Smoking cessation is an important component of lung cancer management and continued abstinence after a diagnosis of lung cancer is associated with reduced recurrence, improved quality of life, and survival. We conducted a phone survey on patients who had undergone surgical resection for Stage 1 non-small cell lung cancer (NSCLC) in St. James Hospital in 2012–2013. Patients were asked about their smoking habits and at 5 time points, Q0 6 months pre-diagnosis, Q1 1 month post surgery, Q2 3 months post surgery, Q3 6 months post surgery and Q4 1 year post surgery. Of 132 patients alive, 85 results were available, Tabe 1

S. Keogan, A. Burns, L. Clancy TobaccoFree Research Institute Ireland The need to control tobacco is probably the most important health intervention. Tobacco dependence is a recognized life-destroying disease. It is therefore very important that all Healthcare Professionals (HCP’S) are educated and feel competent as role models to enable the treatment of tobacco dependence. Total sample (n = 1257) collected by survey monkey was composed of 833 (67.9 %) females and 394 (32.1 %) males. The majority were female (67.9 %) and were mostly in the 30 to 44 (42.5 %) and 45 to 64 (42.5 %) age groups. Overall over 95 % agreed that HCP’s should routinely ask patients about their smoking habits. 94 % of HCP’s agreed that they should routinely advise their smoking patients to quit. Profession and smoking history were significantly associated with this belief. More of the never smokers (95.4 %) felt that those in their profession

Gender

58 % Female

Mean age

67.6 years (47–84)

Q0 Current smokers Q0 Ex-smokers

45 (52.9 %) 32 (37.7 %)

Never smokers

8 (9.4 %)

Q1 1 month abstinence

78 %

Q2 3 month abstinence

80 %

Q3 6 month abstinence

78 %

Q4 12 month abstinence

76 %

Sustained quitters

73 %

Intermittent quitters

9%

Sustained smokers

18 %

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S512 Of the 10 patients smoking at the time of interview, 8 were actively trying to quit with e-cigarettes being the most common. Current smoking consumption had reduced from pre-operative levels, with patients smoking on average 12.7 cigarettes/day compared to 17.8 cigarettes/day previously. Only 50 % recalled being offered smoking cessation counselling peri-operatively, and only 20 % were accepting of further smoking cessation counselling when offered. Long-term smoking cessation rates are high post curative resection of primary lung cancer. Patients who do not quit pre-operatively are at significant risk of continued smoking and require continued encouragement and advice in post-operative follow-up.

3.14. The Prescription of Oxygen on Discharge Letters to Early Supported Discharge Service in Western Health and Social Care Trust K. Donnelly, J. Hughes, A.M. Kernaghan, A. Box, A. Kennedy, C. Farren, H. Patterson Early Supported Discharge Nursing Team, Western Health and Social Care Trust, Northern Ireland The BTS guidelines (2008) for emergency oxygen use in adult patients provide guidance on with the prescription, administration and monitoring of oxygen therapy. It states ‘‘…the intentions of the clinician who initiates oxygen therapy should be communicated clearly to the person who actually administers oxygen to the patient…’’. This is further supported by the WHSCT Policy for the Prescription and administration of Emergency Oxygen in Adults (2012). We wished to re-examine oxygen prescription (and communication to other staff) of patients who were referred to Early supported discharge (ESD) team from 01/01/14 to 28/02/14. A data collection sheet was devised in previous year, guided by the recommendations from BTS (2008). Preliminary finding show an improvement on prescriptions on discharge letters—50 % prescribed for patients in Altnagelvin and 33 % for those in SWAH, as opposed to [5 % last year. Although a welcomed improvement, oxygen is still not being prescribed in accordance with national and Trust policies. As part of the trusts oxygen policy we have introduced oxygen prescription for all in-patients, included a section on oxygen prescription on all discharge letters and in addition the BTS oxygen education module is available to all hospital staff.

3.15. The Benefits of an Oxygen Therapy Clinic in Assessing Oxygen Requirements in Patients with Chronic Respiratory Disease? A. Corrigan, M. O’Reilly and R. Reilly Department of Physiotherapy, Our Lady of Lourdes Hospital, Drogheda, Louth, Ireland The purpose of this study was to establish an Oxygen Therapy Clinic (OTC) and to assess whether patients referred to an OTC required new or changed prescriptions of Oxygen, following assessment. The study took place over 12 months and 82 patients were assessed. Guidelines recommend that any patient discharged home from hospital on new LTOT should have their prescription reviewed 5

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 weeks later. In this group 9 fitted the criteria for removal, 7 continued to require it and 9 required a prescription change. Of the 13 patients in the initial assessment for LTOT group 7 required it. There were 15 patients in the initial assessment for ambulatory oxygen group of these 3 required it. Of the 28 patients in the review of prescription group, 1 patient fitted the criteria for removal, 11 required a prescription change and 8 required no change The results of this study confirm the benefits of an OTC. 10 patients assessed in the OTC had their therapies discontinued, resulting in a cost saving of €21,604.32 Twenty patients assessed in the OTC required a change to their prescription. An OTC optimises oxygen prescription, ensures best patient care and effectively reduces the cost of inappropriate oxygen prescribing.. Reference: 1. British Thoracic Society Working Group on Home Oxygen Services Clinical Component for the home oxygen service in England and Wales 2006 London.

3.16. Bridging the Gap Between Evidence and Practice in the Use of Oxygen Therapy for Adults in Hospital M.O’Donnell Sligo Regional Hospital, Sligo The purpose of this project was to provide healthcare professionals with a process and tools for incorporating evidence-based practice in relation to oxygen therapy use for adults in hospital. The overall objective was to improve patient outcomes by integrating current best practice guidelines. The design of an evidence-based poster on oxygen therapy use in adults in hospital provides a tool for integrating evidence within a medical unit and may improve patient outcomes. An audit of oxygen therapy use in adults in an acute medical ward, in addition to a survey of healthcare staff on their understanding of oxygen therapy use, revealed that practice was not in line with current best practice guidelines. A concise method was needed to educate staff and interpret the evidence needed to improve practice at the bedside. The importance of prescribing, administering and monitoring oxygen therapy to a target saturation range is central to best practice in oxygen therapy use for adults. The target design in centre of poster aims to highlight the importance of maintaining oxygen saturations within prescribed target saturation range to prevent both hypoxaemia and hyperoxaemia. It is hoped that the evidence-based poster on oxygen therapy use for adults in hospital may be useful in bridging the gap between evidence and practice.

3.17. Evidence Based Guideline for Emergency Oxygen Therapy Authors: M. Murphy, M.Geeham, P. Hallahan, U. Clarke, A. Cronin, P. Quinn, B Bowen ANAIL: The Irish Respiratory Nurses Association have published an evidence based guideline for emergency oxygen therapy for use nationally across Ireland. The aim is to encourage the safe use of oxygen therapy in emergency situations and improve consistency of clinical practice in all departments. The purpose of this guideline is to

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 summarise the recommendations for emergency oxygen therapy in all hospital settings across the HSE. Oxygen is a Drug: It should be prescribed. Oxygen Therapy is the treatment for hypoxemia, not breathlessness. It should always be prescribed according to a target saturation range. A working Group from ANAIL was set up in March 2014 to review all hospital guidelines and develop a national guideline. The guideline will be disseminated September 2014 healthcare professionals for consultation.

3.18. Irish Guidelines on Long Term Oxygen Therapy

S513 A working group from Ana´il (Respiratory Nurse Association of Ireland) was established to examine the new guidelines, develop an easy to follow Irish version and a generic prescription sheet. All new research was compiled into this condensed guideline and disseminated amongst Ana´il members for review. Feedback from Ana´il members revealed that oxygen prescribing, management and follow up varies vastly throughout Ireland. Definitive guidance on prescribing was found to be required. The new guidelines from the BTS are very comprehensive but adjustments were required to make them relevant to the Irish health care setting. Future plans are in place to develop a clear model of care for the prescribing, management and follow-up of home oxygen therapy.

Bowen, B. Cronin, A. Davis, P. Donohue, N. Fox, D. Langan, D. Lee, O. Tooher, A. Ana´il Long Term Oxygen Therapy (LTOT) working group The soon to be published British Thoracic Society (BTS) guidelines on long term oxygen therapy (LTOT) are more comprehensive than has been presented before. A working group was commenced to review how these guidelines should be adapted to make them relevant to the Irish healthcare setting.

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Irish Thoracic Society Poster Review and Discussion Friday 7th November 2014

4. Interstitial Lung Disease and Rarer Respiratory Disorders Chairs

D. O’Callaghan, Mater Misericordiae University Hospital, Dublin C. Rooney, Mayo General Hospital, Castlebar, Co Mayo

4.1. Serum Fibroblastic Growth Factor 23 in Acute Sarcoidosis and Normal Kidney Function A. Garrahy1, D.J. Sexton1, M.W. O’Reilly1,2, P. Geoghegan1, P.J. Moran1, A. Talbot1, A.W. O’Regan1 Department of Respiratory Medicine, Galway University Hospital 2 Department of Endocrinology, University of Birmingham, Birmingham, UK Serum fibroblastic growth factor (FGF) 23 is a major regulator of phosphate homeostasis in hyperphosphataemic states such as chronic kidney disease. However its role in states of disordered phosphate homeostasis and normal kidney function is unknown. We examined the characteristics and determinants of serum FGF23 in patients presenting with acute sarcoidosis by conducting a cross sectional study on a sample of patients presenting at a respiratory tertiary referral unit. We studied 39 patients, 26 were male. Mean (SD) age was 33 (9.6) years. 15.4 % of patients had a serum level of FGF23 C 9.9 pg/mL. Those with a detectable serum FGF-23 had a significantly higher serum calcium (P = 0.007), and lower serum iPTH (P \ 0.001). Serum phosphate and 25OH vitamin D were not statistically significantly different between groups (P = 0.25, P = 0.83). The proportion of patients with stage II disease on CXR was higher in those with a detectable FGF-23 (P \ 0.001). In this cohort of patients presenting with acute sarcoidosis a detectable serum FGF-23 was associated with a higher serum calcium and lower iPTH. Given the accumulating evidence of a causal role of FGF23 in adverse cardiovascular and bone outcomes, the significance of FGF23 in patients with sarcoidosis merits further investigation.

4.2. The Information and Support Needs of Individuals Living with Sarcoidosis: A Qualitative Descriptive Study C. McGrath University Hospital Limerick Sarcoidosis is defined by many researchers including Drent (2011) as an inflammatory condition with specific granulomatous

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manifestations which can affect all organs in the body and typically affecting young individuals. The aim of the study was to explore the information and support needs of individuals living with Sarcoidosis to then generate knowledge on what these individuals perceive as necessary in order for them to live a healthy informed life. This study identified the views of individuals living with Sarcoidosis on the formal and informal resources they perceive as important to maintaining their health and wellbeing along with the health professionals key to delivering that information. The qualitative descriptive approach was chosen to exemplify the perceptions of individuals living with Sarcoidosis. A total of twelve participants, seven male and five female were interviewed. The themes emerged as the following; Need to Know, Need for Integrated Care, Need to be Heard and Need to be Understood. Findings revealed patient’s need to know about Sarcoidosis from diagnosis and beyond in various formats. But, in particular information to be delivered by ‘‘Someone who knows’’ a key person, a facilitator or health care professional to the individuals with Sarcoidosis. The findings revealed that individuals’ require an interdisciplinary approach to their care which would encompass a self-management programme. Finally the need to be heard and the need to be understood exemplifies these individuals need for general awareness among health care professionals, families, employers and society in general within Ireland. To have regular contact with a health care professional perhaps a Clinical Nurse Specialist who would focus on Sarcoidosis to allow questions or to clarify information regarding the condition was a possible recommendation for the future. More community awareness may increase a public political drive in developing policies by management within the Department of Health for individuals with Sarcoidosis in Ireland for the future.

4.3. A 6 month Prospective Longitudinal Study of EBUS-TBNA Diagnosed Sarcoidosis to Assess for the Manifestation of an Alternative Pathology over Time D. Ryan, J. Scott, D. Breen, A. O’Regan Galway University Hospital Diagnosis of sarcoidosis usually requires demonstration of typical lesions in one or more organ systems and exclusion of other disorders known to cause granulomatous disease [1]. Endobronchial ultrasound aspiration (EBUS-TBNA) of intrathoracic lymph nodes has diagnostic yield for non-caseating granulomas of 90 % in patients with mediastinal adenopathy and clinical suspicion of sarcoidosis [2]. However, other pathologies can cause non-caseating granulomas. The aim of this study was to follow a cohort of patients diagnosed with sarcoidosis using EBUS_TBNA with routine clinical examination and investigations and assess if alternative pathology became evident over time. A prospective longitudinal study was carried out on 19 patients diagnosed with sarcoidosis with aid of EBUS-TBNA in Galway University hospital. Patients were enrolled if diagnosis was made 6 months prior to study. Identified patients were invited to attend follow up investigations and clinical examination. Results: 11 parameters were measured at diagnosis and follow up. INV (n = 19)

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Investigation

At diagnosis

[6/12 post DX

Average FEV1 (%)

99 %

103 %

Average FEV1/FVC (%)

74 %

72 %

DLCO

86 %

93 %

Adj calcium

2.29

2.35

(Average) Lymphocytes

1.24

1.28

LFTs

NAD

NAD

Average CXR stage

1.17

0.68

Eye symptoms

1

0

Skin signs (E. Nodosum)

4

0

Joint symptoms

7

2

Resp symptoms

12

9

Fatigue

10

1

Alt Dx

0

0

Table 1 % prevalence of circulating fibrocytes in our study cohort Values as Mean +/Std Error of Mean (n = 3)

No alternative diagnosis was made during follow up. Of 19 patients, eight underwent treatment with steroids. While there are other causes of non-caseating granulomas that cause disease, this study suggests no evidence of alternative diagnoses manifesting after time in patients whose diagnosis of sarcoidosis was obtained via EBUS-TBNA. This adds to evidence that EBUS is an accurate adjunct in diagnosing sarcoidosis. References: 1. American Thoracic society, statement on sarcoidosis 2. Nakajima T, Yasufuku K, Kurosu K, et al (2009) The role of EBUS-TBNA for the diagnosis of sarcoidosis—comparisons with other bronchoscopic diagnostic modalities. Respir Med, 103:1796

4.4. Dysregulation of Circulating Fibrocytes in Health and in SmokingRelated Fibrogenic Lung Disease States 1

1

1

1

1

Results: There was no significant difference in the number of circulating fibrocytes between COPD smokers (p = 0.40) or IPF smokers (p = 0.34), compared to age matched smokers without lung diseases. Furthermore, no significant difference is observed in circulating fibrocytes in IPF smokers with IPF nonsmokers (p = 0.89). As expected, fibrocytes are upregulated in IPF patients combined as compared to all other subjects combined (p = 0.047) and significantly higher than in COPD smokers (p = 0.016). They trend to be at higher concentration in IPF smokers in comparison to COPD smokers (p = 0.18). Conclusion: There are concordant trends towards decreasing number of fibrocytes in smokers as compared to nonsmokers across different disease states. The highest number of fibrocytes was in IPF nonsmokers with lowest in COPD smokers (Table 1). Reference: 1. B Mehrad et al. Bioch Biophy Comm 2007 PMID: 17174272

2

F. Khan , E.P. Judge , J. Das , D. White , S. Walsh , R. Kane , J. Worrell,2, R. Lumsden2, A. Fabre3, E. Cotter2, M.P. Keane1, M.W. Butler1 1

Respiratory Department, St Vincent University Hospital, Dublin, UCD Conway Institute of Biomolecular and Biomedical research, Dublin, 3Pathology Department, St Vincent University Hopital, Dublin

2

Introduction: The mechanisms underlying the fibrotic lesions observed in chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF), two smoking associated diseases, are imperfectly understood. Objectives: Are circulating fibrocytes dysregulated in, 1. Smokers with COPD or IPF compared to matched smokers with no known lung disease? 2. Smokers with IPF compared to nonsmokers with IPF? Methods: Fibrocytes are isolated from peripheral blood mononuclear cells and defined as cells positive for CD45, Col1 and CXCR4 by flow cytometry1. They are quantified in three patients from each group including healthy nonsmokers, smokers without lung disease, COPD smokers, IPF nonsmokers and IPF smokers.(n = 15)

4.5. Bronchoscopic Cryobiopsy: Initial Experience in an Interstitial Lung Disease Centre J.P. O’Donovan1, K.A. Khan1, L. Burke2, D.M. Murphy1, B.P. Plant1, M.T. Henry1, M.P. Kennedy1 1

Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland, 2 Department of Histopathology, Cork University Hospital, Cork, Ireland Bronchoscopic cryobiopsy increases the size and potentially the diagnostic yield of transbronchial lung biopsy and allows central biopsy and debulking in patients receiving high oxygen concentration. We prospectively included all patients undergoing bronchoscopic cryobiopsy in Cork University Hospital over an 8 month period. Patients were enrolled following discussion at regional multidisciplinary meetings. All patients had a post procedure chest X- ray. Complications and sample-quality variables were assessed. All 14 procedures (1 central, 13 peripheral) were assessed, 46 % (6) of the patient population were female and average age was 66.5 years (29–78 years). Average FEV-1 was 1.88 L (0.98–2.26) or 73.04 % (48.4–99.5 %) predicted. Adequate cryobiopsies were obtained in 13/14 (93 %) cases (Table 1) with an average of 2.4 (1–4) samples obtained per procedure and an average sample size of 6.8 mm2 (4–18 mm2). Only one patient proceeded to surgical video assisted thoracoscopic biopsy and no patient required CT guided biopsy. Complications included two (14 %) episodes of excessive bleeding controlled during bronchoscopy and two (14 %) pneumothoraces which did not require intercostal drainage. In our study, bronchoscopic cryobiopsy was diagnostic in the majority of patients, negating the need for surgical biopsy with a low rate of complication.

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Table 1 Crybiopsy

Gold standard

4.8. Lung Transplantation in Patients with IPF and Asymptomatic Coronary artery Disease

Interstitial lung disease

7

8

P. Riddell, K, Redmond, D, Eaton, L. Nolke, H. Javadpour, J. McCarthy, D. Healy, J.J. Egan

Sarcoid

3

3

Drug related lung disease

1

1

Inflammation/pneumonitis

1

Unknown (pre VATS)

Inadequate Central biopsy

1

Peripheral biopsies

Inflammation

1

1

Total

14

14

4.6. Differential Expression of CXCR3 by Normal Human and IPF Lung Fibroblasts J. C. Worrell1, S.M. Walsh2, D.A. Boylan1, R. Kane1, M.P. Keane2 1 UCD Conway Institute of Biomolecular and Biomedical research, University College Dublin, Belfield, Dublin 4, Ireland. 2Department of Respiratory Medicine, St Vincent’s University Hospital and School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive form of idiopathic interstitial pneumonia, characterized by fibrosis. The chemokine receptor CXCR3 has a non-redundant role in limiting fibrosis following lung injury. IL-13 is a pro-inflammatory cytokine that mediates the development of fibrosis and it can induce expression of and bind to its own receptor IL-13Ra2. Primary human lung fibroblasts were obtained via explant culture from both control and IPF patient tissue and validated using immunofluorescence and Western blotting. Fibroblasts were treated with various cytokines, and the expression of IL-13Ra2 and CXCR3 were measured. Soluble collagen and proliferation were examined using Sircol and BrdU assays, respectively. We have shown for the first time that both IPF and Normal human primary human fibroblasts express CXCR3. There was significant difference in basal soluble collagen production between patient fibroblasts. Fibroblasts treated with IL-13 at 24 h produced more soluble collagen and changes in Col1A1, IL-13Ra2 and CXCR3 gene expression were also observed. IPF fibroblasts have decreased CXCR3 expression compared to controls and significantly increased IL-13Ra2 gene expression compared to control fibroblasts. Further elucidation of the reciprocal relationship between IL13Ra2 and CXCR3 may lead to identification of new therapeutic targets for pulmonary fibrosis.

4.7. The Irish Lung Fibrosis Association’s 2000 Steps a Day Challenge: A Pilot Study to Evaluate a Novel Home Exercise Programme for Lung Fibrosis Patients N Cassidy1, I.A. Byrne2,3, D. Danaher2, J.J. Egan3 1

The Irish Lung Fibrosis Association, Dublin, Ireland, 2Department of Physiotherapy, Mater Misericordiae hospital, Dublin, 3 The National Lung Transplant Unit, Mater Misericordiae University Hospital, Dublin, Ireland

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Lung Transplant Programme, Mater Misericordiae University Hospital, Dublin Introduction: Lung transplantation significantly improves the survival of patients with advanced IPF. Concurrent coronary artery disease (CAD) limits access to this therapy [1]. We sought to determine the impact of asymptomatic CAD on post-transplant survival. Methods: This retrospective study reviewed all patients who were transplanted for IPF at our centre, between May 2005 and April 2014. We compared post-transplant outcomes in patients with normal and abnormal coronary angiography (at the time of transplant listing). Kaplan–Meier curves and Log-Rank scores were used for statistical analysis. Results: During this period, 39 patients underwent lung transplantation for IPF. All patients had normal left ventricular function. 56.4 % had abnormal coronary angiography. One patient required coronary artery stenting prior to transplant listing. Other patients were managed conservatively (no inducible ischaemia identified on stress testing). Post-transplant survival in the patient group with CAD was 95.7 % at 1 year and 70.1 % at 5 years. This was not significantly different (p = 0.52) in the cohort with normal coronary arteries. Conclusion: Although CAD remains a relative contraindication to transplantation, the effects of previous PCI or minor CAD are unknown and may be overstated. This finding is particularly relevant for patients with IPF, who may have an increased prevalence of CAD [2]. References: 1. Orens JB, Estenne M, Arcasoy S, et al (2006) International guidelines for the selection of lung transplant candidates. J Heart Lung Transplant, 25(7):745–55 2. Raghu G, Weycker D, Edelsberg J, Bradford WZ, Oster G (2006) Incidence and prevalence of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med, 174(7):810–6

4.9. Methotrexate and Lung Disease—A Meta-Analysis of Randomized Controlled Trials R. Conway, C. Low, R. Coughlan, M.J. O’Donnell, J.J. Carey Department of Rheumatology, Galway Univeristy Hospitals, Merlin Park, Galway National University of Ireland, Galway Methotrexate is widely used to treat a variety of inflammatory diseases but its effect on pulmonary morbidity and mortality has not been determined. Our aim was to evaluate the relative risk of pulmonary adverse events in methotrexate treated patients. We performed a meta-analysis of double-blind randomised controlled trials of methotrexate versus placebo or active comparators in adults with rheumatoid arthritis, psoriatic arthritis, psoriasis or inflammatory bowel disease. The Mantel–Haenszel method was used to assess total respiratory adverse events, infectious respiratory adverse events, non-infectious respiratory adverse events and death. Results were expressed as relative risks (RR) with 95 % confidence intervals. A total of 29 studies with 10,214 participants met our inclusion criteria. Heterogeneity across the studies was not significant

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 (I2 = 3 %). Methotrexate was associated with an increased risk of all adverse respiratory events, RR 1.10 (CI 1.02–1.19), and respiratory infections, RR 1.11 (CI 1.02–1.21). Patients treated with methotrexate were not at increased risk of non-infectious respiratory events, RR 1.02 (CI 0.65–1.60) or pulmonary death, RR 1.53 (CI 0.46–5.01). A subgroup analysis of studies reporting pneumonitis revealed an increased risk with methotrexate, RR 7.81 (CI 1.76–34.72). Methotrexate was associated with a small but significant increased risk of infectious but not non-infectious pulmonary adverse events.

4.10. Investigating the Potential Origins of the Myofibroblast in Idiopathic Pulmonary Fibrosis S.M. Walsh, J.C. Worrell, D.A. Boylan, R. Lumsden, A. Fabre, R. Kane, M.P. Keane

S517 Mercy University Hospital, Cork, Ireland in 2003, 298 patients were referred for screening by July of 2013. The HHT database in the national centre was analysed to describe demographics, clinical manifestations and interventional procedures in all referred patients. Contrast echocardiography and/or Thoracic CT were performed in 131 patients with definite HHT identifying 39 with pAVM’s, 20 of whom were referred for single/multiple embolisation procedures. Cerebral MRI was performed in 120 of definite HHT patients with 5 having cAVMS’s. One of these required coiling. Genetic screening was performed in 22 patients with 12 testing positive for either endoglin or activin-receptor-like kinase 1 gene mutation. The prevalence of HHT is thought to be 1 in 5,000–8,000, suggesting many undiagnosed cases in Ireland. International published data suggests a prevalence of 20–40 % for pAVM’s and 15–25 % for cAVMs in patients with HHT. The prevalence of cAVM is considerably lower in the Irish population suggesting difference in genotype and phenotype.

School of Medicine and Medical Science, Conway Institute, University College Dublin Idiopathic pulmonary fibrosis (IPF) is the most common form of idiopathic interstitial pneumonia. The key effector cell is the myofibroblast. Recruitment of myofibroblasts is from at least three sources, including: fibroblasts, fibrocytes and epithelial cells. However, the relative contribution and phenotype of each potential source remains unclear. This study examines the differential gene expression and functional characteristics of each differentially derived myofibroblast. Human pulmonary fibroblasts, fibrocytes and epithelial cells were transitioned to myofibroblasts using TGF-b and TNF-a. Real time PCR, western blotting and immunofluorescence confirmed myofibroblast transition. A human fibrosis PCR array, soluble collagen assay and proliferation assay were performed. The myofibroblast derived from the resident fibroblast displayed the most profibrotic profile, with increased gene expression of profibrotic genes (collagen 1A2, gremlin1, CTGF); genes involved in extracellular matrix remodelling (MMP2, TIMP2); and genes involved in signal transduction (decorin, latent TGF-b-binding protein 1, TGF-b2). Myofibroblasts derived from normal fibroblasts were most proliferative, followed by myofibroblasts derived from epithelial cells. There was no difference in soluble collagen levels. This study identified differences in gene expression between the myofibroblast populations in IPF. Each myofibroblast has its own unique genetic profile. Further study of the genes involved will provide new insights into IPF fibrogenesis.

4.11. An Overview of the Irish National Centre for Hereditary Haemorrhagic Telangiectasia 2003–2013

4.12. Early Experiences with Macitentan Therapy for the Treatment of Pulmonary Arterial Hypertension (PAH) C. Minnock, M. Murray, S. Gaine National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland Macitentan, a new dual endothelin receptor antagonist, was approved for the treatment of PAH in December 2013. Here we present a retrospective review of the initial PAH patients treated with macitentan at the National Pulmonary Hypertension Unit in Ireland. Patients’ demographic and clinical characteristics are reported at the start of treatment. Tolerability of macitentan are reported after 1 month treatment. Currently, six patients aged on average 56 ± 18.3 years have started treatment with macitentan. Four patients (66.6 %) were female, three patients had associated PAH, one patient had idiopathic PAH and two patients had portopulmonary hypertension. Four patients had PAH in World Health Organization functional class (WHO FC) III, two were in WHO FC II. Two patients were previously treatment naı¨ve, four was treated with sildenafil and one with an inhaled prostanoid. Two patients were switched from bosentan to macitetan and four patients had macitentan added to their treatment regime. One patient received macitentan following a new diagnosis, two patients received macitentan due to concomitant liver safety problems, and three due to intolerance to other treatments. For all patients macitentan was well tolerated after 1 months’ treatment.

L.J. Chawkea, D.B. Fitzgeralda, J.M. O’Gradya, A. Bradyb, M. Murphyb, T.M. O’Connora a

Department of Respiratory Medicine, National HHT Centre, Mercy University Hospital, Grenville place, Cork, Ireland. bDepartment of Radiology, National HHT Centre, Mercy University Hospital, Grenville Place, Cork, Ireland Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterised by the development of abnormal dilated vessels. This syndrome may manifest as recurrent epistaxis with pulmonary and cerebral arterio-venous malformations (AVMs). Since the foundation of the Irish National Centre for HHT in The

4.13. Out-Patient Management of Patients with Venous Thromboembolic Disease A. Purcell, V. Pradeed, Y. Smyth, E. McMahon Acute Medical Assessment Unit, Galway University Hospital Deep venous thrombosis (DVT) is a common hospital presentation with an incidence of 1–3 cases per 1,000 adult cases. The management for DVT has been predominately managed on an in-patient basis

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S518 and newer anticoagulants such as dabigatran, apixaban and rivoraxaban have the added benefit of less drug interactions and less monitoring compared to heparin based alternatives. Multiple control trials have demonstrated the safety and efficacy of out-patient management of DVT, however strict selection criteria apply. In the Acute Medical Assessment Unit (AMAU), a pilot programme of out-patient management of DVT is currently implemented. A protocol was developed in conjunction with Emergency Department (ED) staff in which any cases of confirmed DVT are referred to AMAU for further assessment for suitability for out-

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 patient management. Seventeen patients were deemed suitable candidates for out-patient management with oral rivaroxaban. These patients were reviewed by an AMAU consultant a further three times to ensure compliance, assess for any complications including extension of DVT and to evaluate renal function. Of the 17 patients one had DVT expansion and another required a change to warfarin due to deterioration in renal function. The programme has conferred significant benefit to both hospital and patients.

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Friday 7th November 2014 Chairs

T. O’Connor, Mercy University Hospital, Cork S. Donnelly, AMNCH, Tallaght Hospital, Dublin

5.1. High Prevalence of Non-smoking Related Obstructive Lung Disease in Farmers in Ireland B. Cushen1, N. Donoghue2, D. Langan1, T. Cahill1, E. Nic Dhonnacha1, O. Healy1, F. Keegan1, M. Browne3, I. Sulaiman4, A. O’Regan1 1

Department of Respiratory Medicine, Galway University Hospital, Department of Respiratory Medicine, Bon Secours Hospital, Galway, 3NUI Galway, 4 Royal College of Surgeons in Ireland

2

International studies have found that farmers have a high prevalence of respiratory complaints, however, little is known about respiratory health in farmers in Ireland. A recent study has shown that farmer’s general health has lagged behind other professions for unclear reasons. We undertook a cross-sectional assessment of farmers lung health at the 2013 Ploughing Championships. A key component of this study was respiratory scientist measured spirometry. Results were correlated with variables related to respiratory disease. 402 farmers volunteered with 372 undergoing spirometry. Overall the prevalence of airflow obstruction was 12 %. Of those with obstruction 66 % were never smokers. The presence of obstruction was significantly associated with previous history of respiratory disease (p \ 0.0001) and BMI [ 25 kg/m2 (p \ 0.05). There was no significant correlation between the presence of airflow obstruction and home/occupational exposures. Non-smokers with obstruction were significantly more likely to report a history of asthma and hay fever/ allergies (p \ 0.05) and to complain of dyspnoea or wheeze (p \ 0.0089). This large comprehensive assessment of lung disease in farmers demonstrates a remarkably high prevalence of obstructive lung disease in non-smoking subjects compared with international levels. Airflow obstruction was greatest in those with previous diagnosis of respiratory disease and with higher BMI.

performed a retrospective review of positional therapy in a tertiary referral centre. 111 patients referred for positional therapy with the Zzoma Positional DeviceTM were reviewed. The apnoea-hypopnoea index (AHI) pre-treatment was compared to that on treatment. Compliance with therapy was assessed. Statistical analysis was performed using the paired t test using SPSS. 47 patients had a follow-up limited sleep study performed on PT. The mean AHI improved from 15.8/h pre-treatment to 4.58/h while using PT (p = 0.0001). Of the remainder, limitations to uptake and compliance mainly related to cost and device comfort. Data regarding outcomes of PT is limited. Van Maamen et al. recently published a multicentre study showing significant improvements with PT in POSA [2]. Our data indicate that positional therapy has a significant role in management of OSA. References: 1 Frank MH, Ravesloot MJL, van Maanen, Verhagen E, de Lange J, de Vries N. Positional OSA part 1: towards a clinical classification system for position-dependent obstructive sleep apnoea. Sleep Breath 2014 Jun 19. [Epub ahead of print] 2 van Maamen JP, de Vries N (2014) Long-term effectiveness and compliance of positional therapy with the Sleep Position Trainer in the treatment of positional obstructive sleep apnea syndrome. SLEEP 37(7):1209–1215 Comparison of Mean AHI Pre-treatment vs on Positional Therapy 18.0 16.0 14.0 12.0

AHI

5. Irish Thoracic Society Oral Presentations I

S519

10.0 8.0 6.0 4.0 2.0 0.0

Pre-treament

On Positional Therapy

5.3. Inflammatory Induced ER Stress in Cystic Fibrosis Neutrophils is Reduced by Ivacaftor Treatment M. White, B. Alfawaz, S. Cox, E. Hayes, N.G. McElvaney, E.P. Reeves Royal College of Surgeons, Ireland

5.2. Positional Therapy is a Cheap and Effective Alternative to Continuous Positive Airway Pressure in Position-Associated Obstructive Sleep Apnoea D.B. Fitzgerald, L.J. Chawke, J.S. O’Sullivan, M. Rafferty, A. O’Mahony, T.M. O’Connor, D.R. Curran Department of Sleep and Pulmonary Medicine, Mercy University Hospital, Cork The role of sleep position in obstructive sleep apnoea (OSA) is well recognised. Positional therapy (PT), when appropriate, may provide a cheap and effective alternative to continuous positive pressure therapy. The Amsterdam Positional OSA Classification (APOC) has been recently published [1] and, with the development of improved positional therapy devices, the use of PT is likely to increase. We

Cystic fibrosis (CF) is an inherited disorder characterised by neutrophil dominated inflammation. Why neutrophils are dysregulated in CF remains unclear. The aim of this study was to evaluate the effect of inflammation on endoplasmic reticulum (ER) stress related structural changes of circulating neutrophils in CF with focus on changes in cholesterol content of CF neutrophil lipid rafts. Neutrophils and plasma were isolated from healthy controls (HC) and patients with CF homozygous and heterozygous for the DF508 and G551D mutation and pre- and post-treatment with ion channel potentiator ivacaftor. Neutrophils were fractionated by ultracentrifugation. Western blot analysis determined expression of ER stress markers GRP78, ATF6 and the cholesterol trafficking protein caveolin-1. Cholesterol was quantified fluorometrically. Statistical significance was calculated by student’s t test. Ethical approval was obtained from Beaumont Hospital Ethics Committee. Results demonstrated inflammatory induced ER stress with increased ATF6 (n = 10, p = 0.02) and GRP78 (n = 11, p = 0.04)

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S520 expression resulting in reduced caveolin-1 (n = 6, p = 0.03) expression and lipid raft cholesterol content (n = 5, p = 0.02) in DF508 CF neutrophils. Patients receiving ivacaftor had reduced plasma levels of pro-inflammatory cytokines TNFR1 (n = 4, p = 0.01), Nap-2 (n = 4, p = 0.03) and IL-8 (n = 4, p = 0.035). Consequently, GRP78 (n = 4, p = 0.005) was reduced post treatment, resulting in increased caveolin-1 (n = 3, p = 0.03), and membrane cholesterol content (n = 4, p = 0.04). Our results suggest ivacaftor treatment limits pro-inflammatory cytokines, likely facilitated by improvements in lung function in patients with CF. The capacity of a mediator of inflammation to influence neutrophil structure and function is a beneficial effect of treatment. Funding: This study was funded by Science Foundation Ireland, Grant number 11/RFP/BMT/309.

5.4. Serum Exosomes from IPF Patients Display a Fibrotic miRNA Profile and Induce Collagen Production In Vitro Rosemary Kane1*, Robert V. Lumsden1*, Sharon Whitty1, Denise Boylan1, Sinead Walsh1,2, Julie Worrell1, Faheem Khan1,2, Seamas C Donnelly1,2, Marcus Butler1,2, Aurelie Fabre1,2, Michael P. Keane1,2 1 UCD Conway Institute of Biomolecular and Biomedical research, University College Dublin, Belfield, Dublin 4, Ireland, 2 Department Respiratory Medicine, St Vincent’s University Hospital and School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland

*These authors contributed equally. Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease characterised by fibrosis, resulting in loss of lung function. Exosomes are extracellular microvesicles that are involved in cell–cell signalling (1), and have been shown to exacerbate disease states, including fibrotic disease (2). This study examined exosomes isolated from the serum of IPF patients (n = 10) and age matched healthy controls (n = 6). We characterised the exosomes by western blot and Nanosight technology. MicroRNA was isolated from these exosomes and was profiled using a miRNA PCR array. Exosomes were also used in functional assays. Exosomes isolated from IPF patients showed decreases in antifibrotic miRNAs such as miR-141, 200b and 19b and increases in fibrosis progressing miRNAs such as miR-125b when compared to healthy controls. When used to treat lung epithelial cells and fibroblasts to assess their effects on fibrotic markers, IPF exosomes increased collagen production as compared to exosomes from healthy controls. We also found that CD63 the exosomal marker was differentially glycosylated in IPF exosomes as compared to healthy control exosomes. This may play a role in exosome function in IPF. This data illustrates the role of exosomes in the exacerbation of fibrotic lung disease and identifies new potential IPF biomarkers and targets for intervention. References: 1. Bang C, Thum T. Exosomes (2012) New players in cell–cell communication. Int J Biochem Cell Biol, 44(11):2060–2064. ¨ zdemir BC, Kato N, Revuelta I, Miller CA, 2. Borges FT, Melo SA, O et al (2013) TGF-b1-Containing exosomes from injured epithelial cells activate fibroblasts to initiate tissue regenerative responses and fibrosis. J Am Soc Nephrol 24(3):385–392

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5.5. Patient Experience of Pirfenidone Use at a Specialist ILD Clinic A. Subramaniam, M. Elshafi, L. Thong, K. O’Halloran, B. Bowen, K.A. Khan, D.M. Murphy, B.P. Plant, M.P. Kennedy, M.T. Henry Department of Respiratory Medicine, Cork University Hospital Pirfenidone is the first therapy for pulmonary fibrosis which alters the natural progression of the disease. We report our experience thus far, of Pirfenidone use at a specialist ILD clinic. We prospectively evaluated the tolerability and change in lung function before and after Pirfenidone therapy. Consecutive patients on treatment with mild/moderate IPF (FEV1 [ 50 % predicted, DLCO [ 35 % predicted) were included. Their demographics, dosing regimen, tolerability, side effect profile and pulmonary function tests were recorded from chart review. All 51 patients on Pirfenidone were analysed. 35 were males. The mean age was 72.5 years (56–88 years). The mean FVC % (L) and DLCO % (ml/min/mmHg) before and after treatment were 83.30 (2.62) Vs. 77.60 (2.45) and 44.80 (7.2) Vs. 41.4 (6.76). The mean duration of therapy was 10.6 months. The mean decline in FVC was 216.7 ml compared to 235 ml for placebo group in ASCEND study [1] (p value 0.009). 49 patients were still alive and 65 % (33) tolerated maximal dose, 13 patients were on reduced dose due to side-effects and two patients discontinued therapy. 47 % (24) of patients reported side effects on Pirfenidone; of these, 17 % reported rash, 38 % nausea, 25 % diarrhoea, 13 % dizziness, 8 % myalgia and 13 % had abnormal liver profile. The data suggest that Pirfenidone therapy has a beneficial outcome with good tolerability in patients with IPF attending a specialist service. Reference: 1. King TE Jr et al (2014) ASCEND study group. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med, 370(22):2083–2092

5.6. 100 Lung Transplants Delivered In Ireland A. Gough, A.E. Wood, J.F. McCarthy, L. Nolke, D.G. Healy, K. Redmond, D.R. Eaton, H. Javadpour, J.J. Egan National Thoracic Transplantation Service, Mater Misericordiae University Hospital, Dublin 7, Ireland The lung transplant program started in Ireland in 2005. From that point the burden of service delivery was gradually transferred from the prior provider (UK), to a full local national service. By 2014 the program was delivered exclusively through the national service. We report on the first 100 cases. The demographic, clinical and operative data on 100 consecutive lung transplant cases performed were reviewed. Data was collected prospectively on a contemporaneously completed database. The average age was 49.41 years (range 18.45–72.49) and 67 were male. There were 52 single and 48 bilateral sequential lung transplants. The indications for transplant were: IPF (40), Cystic Fibrosis (28), Emphysema/COPD (20) and others including alpha 1 antitrypsin deficiency (4), lymphangioleiomyomatosis (LAM) (2), bronchiolitis obliterans syndrome (BOS) (2), Pulmonary hypertension (2), Sjorgens disease (1) and Sarcoidosis (1). There has been a steady increase in the number delivered in each year with 32 in 2013 alone. The 30 day, 1 and 5 year survival were 99, 98 and 80 % respectively. This new program has delivered steady progress from 2005 to 2014 where it is delivering transplantation services in numbers not previously delivered to Irish patients. Clinical outcomes are excellent and compare favourably with international standards.

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6. Irish Thoracic Paediatric Forum Friday 7th November 2014 Chair

D. Slattery, Children’s University Hospital, Temple St, Dublin

S521 HDU was 37.5 h, and hospital LOS 186 h. 17 infants were studied in 2011/2012. Mean age 5.22 months and mean weight 6.6 kg. There were two transfers to PICU. When transfers were excluded LOS in HDU was 50 h, and hospital LOS was 108 h. There was no evidence from our study that HHHFNC improved respiratory outcomes or transfer rates to PICUs. There was a lower median LOS in HDU in infants treated with HHHFNC.

6.1. Paediatric Respiratory Non-invasive Ventilation Service

6.3. A Comparative Study of Two Medication Groups of Infants with Moderate Bronchiolitis

C. Carrig, M. Devitt, M. McDonald, P. Greally

F. Yasin, Z.S. Afridi, R. Khan

Paediatric Respiratory Department, Tallaght Hospital, Dublin 24

Paediatric Department, Kerry General Hospital Tralee, Ireland

Non-invasive ventilation (NIV) is now an established treatment for children with sleep disordered breathing. An audit of the services provided to children commencing NIV therapy was undertaken to identity areas which require resources in the future. A retrospective chart review was performed on all children initiated on NIV within the service between 2003 to present day. Primary diagnoses, compliance with NIV and patients outcomes were noted. NIV was attempted on 74 patients. Thirty-two per cent (24/74) had endogenous obesity with obstructive sleep apnoea, thirty-two per cent (24/74) endocrine disorders, ten per cent (7/74) neuromuscular disorder, eight per cent (6/74) genetic disorders, seven per cent (5/74) Trisomy 21, eleven per cent (8/74) other disorders. Eighty-three per cent (61/74) were successfully discharged from hospital on NIV. Of the 61 children discharged on NIV, forty-six per cent (34/74) remain within the service of which 22/34 are complaint with therapy while the remaining 12/34 are non-compliant. Thirty-two per cent (24/74) discharged to adult services or other paediatric hospitals, three per cent (2/74) have died and one per cent (1/74) was lost in follow up. The profile of paediatric patients requiring NIV is multifactorial. Multidisciplinary resources and new strategies most be found in order to improve compliance with therapy.

Aim: To compare effect of racemic epinephrine (RE) and 3 % Hypertonic saline (HS) nebulization on length of hospital stay (LOS) of infants with moderate bronchiolitis. Method: Infants with ‘moderate’ bronchiolitis presenting to Emergency were enrolled (October 2013–March 2014) as per defined inclusion exclusion criteria and severity tool [1]. Alternate participants were assigned RE or HS groups and monitored minimum every 4 h. Results: Of total of 80, 16 infants in HS group and 18 infants in RE group were enrolled. The demographics of the two groups were similar. One infant from RE group and 3 from HS group were excluded due to progression to severe disease. In RE group, out of 17 remaining infants, the length of stay ranged between 18 and 160 h (Mean 45 ± 38 h). In HS group, out of remaining 13 infants, the length of stay ranged between 18.50 and 206 h (Mean 83 ± 56 h). The mean ‘length of stay’ in group with RE alone was significantly reduced (t test, p 0.03) as compared to the HS group. No infant in RE group whereas four infants in HS group required oxygen therapy. One patient in RE group and two patients in HS required the intravenous fluids. Conclusion: Racemic Epinephrine nebulization as first-line medication reduces length of hospital stay in infants with moderate bronchiolitis. Reference: 1. http://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis_ Guideline/

6.2. Heated Humidified High Flow Nasal Cannualtion (HHHFNC) Therapy in the Treatment of Bronchiolitis F. Kennedy, D. Finn, B. Elnazir Paediatric Departments, AMNCH Tallaght, Dublin Ten percent of healthy infants with bronchiolitis require paediatric intensive care unit (PICU) admission. In our hospital, if intubation and ventilation is required as part of supportive treatment, transfer to another hospital is necessary for PICU care. Our aim was to assess the effectiveness of HHHFNC for the treatment of moderate bronchiolitis. Infants with moderate bronchiolitis admitted to our HDU over the 2013/2014 season were treated with HHHFNC. They were followed prospectively for respiratory outcomes. For comparison we retrospectively assessed all infants with moderate bronchiolitis admitted to HDU during the 2011/2012 season. Nineteen infants were treated with HHHFNC in 2013/2014. Mean age 5.4 months and mean weight 6.73 kg. There were five transfers to PICU. When transfers were excluded median length of stay (LOS) in

6.4. Title: Life-threatening Post-fontan Plastic Bronchitis: A Paediatric Case Report and Literature Review W.J. Tee1, O. Franklin2, D.W. Cox1 1

Respiratory Department, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland, 2Cardiology Department, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland Introduction: Plastic bronchitis (PB) is a rare condition characterized by the recurrent formation of branching casts causing partial or complete obstruction of the tracheobronchial tree [1]. Case report: A 3‘-year-old boy developed a persistent wet cough 4 months post-fontan procedure for complex congenital heart disease. He subsequently had a sudden cardiopulmonary arrest requiring ECMO. Bronchoscopy revealed branching casts completely

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S522 obstructing the left main bronchus, consistent with a diagnosis of PB. He was placed on an aggressive treatment regimen including nebulised alteplase and is currently stable. Discussion: Treatment for PB is challenging and there is little evidence supporting any one therapeutic option [2–4]. References: 1. Schumacher KR, Singh TP, Kuebler J, Aprile K, O’Brien M, Blume ED (2014) Risk factors and outcome of fontan-associated plastic bronchitis: a case-control study. J Am Heart Assoc. 3(2) 2. Do TB, Chu JM, Berdjis F, Anas NG (2009) Fontan Patient with Plastic Bronchitis Treated successfully using aerosolized tissue plasminogen activator: a case report and review of the literature. Pediatric Cardiol, 30(3):352–355 3. Heath L, Ling S, Racz J, Mane G, Schmidt L, Myers J, et al (2011) Prospective, longitudinal study of plastic bronchitis cast pathology and responsiveness to tissue plasminogen activator. Pediatric Cardiol, 32(8):1182–1189 4. Costello JM, Steinhorn D, McColley S, Gerber ME, Kumar SP (2002) Treatment of plastic bronchitis in a Fontan patient with tissue plasminogen activator: a case report and review of the literature. Pediatrics, 109(4):e67–e67

6.5. The Effects of Vitamin D Supplementation on Pulmonary Function, Disease Severity and Markers of Inflammation in Childhood Asthmatics: A Randomized, Double-Blind, Placebo-Controlled Trial C.P. Kerley1,2, K. Hutchinson3, P. Greally4, D. Coghlan4, B. Elnazir4 1 Unversity College, Dublin, Belfield, Dublin 4, 2Respiratory and Sleep Diagnostics Department, Connolly Hospital, Dublin 15, 3 Biomnis Ireland, Sandyford business Estate, 3 Rock Rd, Dublin, 4 The Adelaide and Meath Hospital, Dublin

Vitamin D deficiency (VDD) and asthma-incidence/severity share many common risk factors. Vitamin D has a number of biological effects that are likely important in regulating key mechanisms in asthma. Thus, VDD may result in increased prevalence and severity of childhood asthma. In Autum/Winter 2013 we recruited 51 children (24 male), aged 5–15 (mean 8.6 year) with a mean body mass index of 19.2 kg/m2 (16.1–31.1) all previously diagnosed with asthma (Dublin, Ireland, 53N). At baseline we assessed pulmonary function, asthma control with the GINA score and the paediatric asthma control test (P-ACT) and quality of life with the paediatric asthma quality of life questionnaire (PAQLQ) as well as biochemical indices of vitamin D status (25(OH)D), calcium (Ca2+), parathyroid hormone (PTH), phosphate (PO43-), allergy (IgE) and inflammation (hsCRP). The intervention was 15 weeks of 2,000 iu vitamin D3/day or placebo. There was no change in medication use. Compliance was high (*84 %) and there were no adverse effects. Of the 51 recruited children, there were 12 dropouts, leaving 39 subjects who completed all assessments. Table 1 displays absolute changes from baseline to endpoint from the 39 completing subjects.

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 Table 1 Absolute changes from baseline to endpoint

N=

Placebo

Vitamin D3

22

17

*P value

Male: Female

13:9

11:6

Atopic

20:2

15:2

GINA

-1 ± 1.9

-1 ± 1.8

0.5

P-ACT

3 ± 6.6

1.4 ± 6.2

0.2

PAQLQ 25(OH)D

5.9 ± 21.2 0.6 ± 8.1

7.6 ± 18.1 52.8 ± 37.5

0.4 0.00001

Parathyroid hormone

3.8 ± 17.9

-1.8 ± 14.7

0.15

Phosphate

-0.1 ± 0.2

-0.1 ± 0.2

0.4

Calcium

-0.1 ± 0.1

-0.1 ± 0.1

0.4

IgE

120.7 ± 429.9

-34.2 ± 113.6

0.07

CRP

-1 ± 3

0.9 ± 2.4

0.02 0.02

FEV1 %

6.7 ± 25.8

-8.6 ± 18.7

FVC %

5.2 ± 23.8

-6.6 ± 21.9

0.06

FVC:FVC

4.3 ± 20.7

-6.5 ± 18.2

0.04

Values presented are mean ± standard deviation * P values are derived from 1 tailed, unpaired T tests In conjunction with a significant increase in 25(OH)D levels, vitamin D supplementation was associated with significant worsening of airway obstruction compared to placebo. Vitamin D replenishment warrants further investigation in paediatric asthma. This work was supported by the National Children’s Hospital Foundation. References: 1. Department of Health. Health in Ireland: Key Trends 2013. Dublin2013 2. Eberhart NK, Sherbourne CD, Edelen MO, Stucky BD, Sin NL, Lara M (2014) Development of a measure of asthma-specific quality of life among adults. Qual Life Res, 23(3):837–848

6.6. Comparison of Two Methods of Inhaler Technique Instruction in Children S. Arthurs, R. Khan, F. Yasin, E. Cahalane, J. Cournane, B. Browne, R. O’Shea Physiotherapy and Paediatric Departments, Kerry General Hospital Asthmatic children and their parents must be educated about inhalers (Brand 2006). It is unknown if DVD education is effective. There is also no gold standard measure to assess inhaler technique. The aims were to establish immediate and longer term effectiveness of DVD inhaler instruction, compared to individual education, and to develop a reliable outcome measure to quantify inhaler technique. All children already using or newly prescribed inhalers over 3 months in a paediatric ward were invited. 21 participants were randomised to DVD or individual education. Technique was assessed pre-education in non-naı¨ve participants. Participants then watched a

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 DVD about valved holding chamber use, or received messageequivalent education from a physiotherapist. Technique was assessed immediately post and 3 months after education with a new outcome measure. Intra-rater and inter-rater reliability of the new measure was examined. There was no significant difference between education formats immediately following or 3 months post intervention, in technique, self-efficacy or knowledge acquisition. The measure demonstrated excellent intra- and inter-rater reliability. Video tutorials were an effective educational medium, but inhaler technique must always be checked by a healthcare professional. The checklist was a reliable measure of inhaler technique, but requires validation from lung deposition studies.

6.7. 5 Year Review of First Time Colonisations of Pseudomonas Aeruginosa in Children with Cystic Fibrosis: Treatment and Outcomes

S523 technique, to assess the ventilation inhomogeneity in respiratory diseases such as cystic fibrosis. The primary aim of this study was to determine a set of control LCI values and against these, examine a set of values for similar subjects (children aged 4–16) with a diagnosis of cystic fibrosis. 46 children were recruited to participate in the study, 23 of whom had a diagnosis of cystic fibrosis and were attending regular clinics at the University Hospital Limerick. A further 23 were recruited through responses from study information material that had been disseminated. The multiple breath washout procedure was performed using the Exhalyzer D by Ecomedics, a minimum of 2 technically acceptable trials were necessary to consider the LCI result obtained and 60 min per subject was deemed to be a feasible timeframe for a clinical setting. Overall results were obtained from 18 control participants and 19 CF subjects. The control values obtained ranged from 6.3 to 7.68, while the CF values ranged from 6.74 to 19.83, with [70 % of the CF subjects results being above the maximum value obtained in control subjects. Additionally the study demonstrated that the MBW technique as performed under the conditions found in this study could produce robust results within a timeframe that would make it acceptable in a clinical setting.

D. Finn, G. Leen, B. Elnazir Respiratory Departments, AMNCH, Tallaght Chronic infection with Pseudomonas aeruginosa (Pa) is an important predictor of mortality, and the most important cause of morbidity in children with cystic fibrosis (CF). In the early phase of Pa infection is possible with antibiotics to clear the lungs of Pa and delay chronic infection. Our aim was to assess outcomes following eradication therapy for initial Pa colonization. All CF patients who had respiratory cultures positive for Pa for the first time between January 2009 and December 2013 were included. Both chart reviews and reviews of laboratory system results took place. 19 patients were identified. Mean age was 3.32 years. 12 (63 %) were delta F508 homozygous. 2 (10 %) children had intravenous tobramycin and the remainder (n = 17, 90 %) had inhaled tobramycin in conjunction with oral ciprofloxacin. 18 (95 %) were Pa free at 28 days. Of these 7 (37 %) are still P aeruginosa negative. The remaining 11 (58 %) are intermittently colonized with P. Aeruginosa and their mean time to next colonization was 1.3 years. As new treatments emerge and life expectancy for children with CF improves, the early treatment of Pa becomes ever more important. Our findings display how appropriate eradication regimens can be successful (95 % eradicated) and delay chronic colonization.

6.8. Determing the Lung Clearance Index of Children with Cystic Fibrosis, Aged 4–16 Versus Healthy Subjects in an Irish Setting L. Keane1, B. Linnane2, J. Saunders3,4, D. Zeugolis5 1

Centre for Adult Learning and Professional Development, University Hospital Limerick, 3Statistical Consulting Unit, University of Limerick, 4Centre for Support and Training in Analysis and Research CSTAR Limerick, 5Network of Excellence for Functional Biomaterials, National University of Ireland

2

6.9 Mycobacterium africanum and Disseminated TB in Childhood: A Case Illustrating a Rare Presentation in the Immunocompetent Host S. Giva1, S. Geoghegan1, C. Hickey2, C. Bogue3, T.M. O’Connor4, D. Mullane1, S.M. O’Connell1 Departments of 1Paediatrics and Child Health, 2Microbiology and 3Radiology, Cork University Hospital and 4Department of Respiratory Medicine, Mercy University Hospital, Cork Mycobacterium africanum (Ma) occurs predominantly in immunocompromised patients. We describe a case of Ma miliary and intracranial TB in an immunocompetent child. A 10 year old boy presented with pyrexia of unknown origin. He had no recent travel or sick contacts. Mantoux was positive. Lumbar puncture confirmed meningitis. MRI brain showed leptomeningeal enhancement and tuberculomas. CT showed classic appearances for miliary TB. HIV and immune workup were negative. FNA histopathology from a supraclavicular lymph node showed caseous necrosis, mycobacterial cultures confirmed Ma. Anti-tuberculosis medications and steroids were commenced. Ma, common in Africa, is rare in Ireland, especially in immunocompetent children. References: 1. Jong BC, Adetifa I, Walther B, Hill PC, Antonio M, Ota M, Adegbola RA (2010) Differences between TB cases infected with M. africanum, West-African type 2, relative to Euro-American M. tuberculosis—an update. FEMS Immunol Med Microbiol, 58(1): 102–105 2. Esteras MAR, Parra IP, Mercade´ MDB (2003) Disseminated Tuberculosis due to Mycobacterium africanum. Arch Bronconeumol, 39 (8):376–377

There has been renewed interest surrounding the use of the lung clearance index obtained through the multiple breath washout

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7. Irish Thoracic Society Oral Presentations II Friday 7th November 2014 Chairs

A. O’Brien, University Hospital Limerick M. Kelly, Altnagelvin Hospital, Derry

7.1. Objective Quantification of Both Time and Technique of Dry Powder Inhaler Use by a Community Based Population of Respiratory Patients I. Sulaiman1, J. Seheult1, E. MacHale2, S. D’Arcy3, F. Boland4, A. Aman1, M Abdullah1, K. McCrory5, J. Casey6, G. Bury7, C. McCarthy1, M.E. O’Brien1, I.J. Meurling1, M. Al-Alawi1, R.B. Reilly3, R.W. Costello1 1

Department of Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland, 2Respiratory Department, Clinical Research Centre, RCSI, Dublin, Ireland, 3Trinity Centre for Bioengineering, Trinity College, University of Dublin, Ireland, 4RCSI Population Health Sciences, RCSI, Dublin, Ireland, 5Primary Care Practice, Finglas Family Practice, Dublin, Ireland, 6Primary Care Practice, Beaumont Park Clinic, Beaumont Woods, Dublin, Ireland, 7 Primary Care Practice, Coombe Medical Centre, Dublin, Ireland The purpose of this study was to quantify adherence to inhaler therapy in a cohort of respiratory patients in primary care. A novel device was attached to an inhaler, recording the acoustic sounds of the inhaler being used, assessing both time and technique of use. A cohort of patients from 6 different primary care practices were given a DiskusTM inhaler with an attached recording device. Subsequent analysis provided objective, quantitative information on inhaler use over time. Fifty-eight patients were given adapted inhalers, eight devices failed to record and eight devices were not returned. Among the forty-two patients for whom acoustic recordings were available there were 2,315 doses taken (by dose counter), an average adherence of 88 %. There were 2013 audio files with actual inhalations, an average adherence of 74 % (p \ 0.05). This difference was due to wasted doses from patients moving the lever more than once, including two instances of dose dumping. Technique errors occurred in 676 (33 %) of all events, including inadequate inspiratory flow (15 %), exhalation (7 %) and multiple inhalations (9 %). Of 60 doses expected to be taken in 1 month, on average 48 doses were attempted and when errors were accounted for, the average number of actual doses taken was 34 doses, p \ 0.01. Analysis of the data indicated that errors in inhaler user technique occurred in one-third of inhalations and tended to occur in most users. These data quantify the rate of two aspects of adherence to inhaled medication, unintentional and haphazard adherence.

7.2. Lower FEV1 and MMEF25–75 and Higher Eosinophil Counts Predict Airway Hyperresponsiveness in Patients with Suspected Asthma J.S. O’Sullivan, L.J. Chawke, D.B. Fitzgerald, D.R. Curran, T.M. O’Connor Department of Respiratory Medicine, Mercy University Hospital, Cork, Ireland

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Methacholine challenge test (MCT) is a commonly used but labour intensive investigation of airway hyperresponsiveness in patients with suspected asthma. We sought to examine the relationship between the MCT PC20 and other variables in an Irish population with suspected asthma. We analyzed 165 patients (78 males) who underwent a MCT in the Mercy University Hospital from July 2010–July 2014. The median MCT PC20 was 3.6 mg/mL (0.03–16 mg/mL). We found statistically significant positive correlations between MCT PC20 and FEV1 % predicted (p \ 0.0001) and MMEF25–75 % predicted (p = 0.0003) and negative correlations between MCT PC20 and house dust mite immunoassay (p = 0.0070), eosinophil count (p = 0.0003) and eosinophils % (p \ 0.0001). There were no significant correlations between MCT PC20 and serum IgE, smoking history, BMI, history of eczema, allergic rhinitis or GORD. Comparing those with positive versus negative MCTs, patients with positive MCTs had lower FEV1 (p \ 0.0001), MMEF25–75 (p \ 0.0001) and higher house dust mite immunoassays (p = 0.0227) and eosinophil counts (p = 0.0034). Using multiple regression, MCT PC20 was predicted by the predicted - 0.9504 9 equation 3.52 + 0.079 9 MMEF25–75 % eosinophils % (p \ 0.0001). Lower FEV1 and MMEF25–75 and higher eosinophil counts (even within the normal range) predict a positive MCT in patients with suspected asthma.

7.3. Effect of Continuous Positive Airway Pressure (CPAP) on Blood Pressure in Patients with Obstructive Sleep Apnoea (OSA) and Resistant Hypertension C. Judge2, F. Daniels1, C. Byrne1, S. Kyvelou1, O. Healy1, J. Garvey2, F. Sharif1, J.J. Gilmartin2 1

Department of Cardiology, Galway University Hospital, Newcastle Rd., Galway, 2Department of Respiratory Medicine, Merlin Park University Hospital, Dublin Rd., Galway Patients from a resistant hypertension clinic were selected to investigate the effect of CPAP on blood pressure (BP) in patients with OSA and resistant hypertension. 22 patients [age 53.3 (SD = 16.7), BMI 37.3 (SD = 5.9)] with OSA [Apnoea-hypopnea Index 31.2 (SD = 15.5), Epworth Score 9.9 (SD = 3.1)] and resistant hypertension were started on CPAP for 6 months. Antihypertensive number and dose were analysed to ensure the results were not attributable to medication titration. The intervention of CPAP elicited a statistically significant mean reduction across all BP values including systolic -9.7 (95 % CI 4.7–14.6), p = 0.001; diastolic -7.3 (95 % CI 3.1–11.5), p = 0.002; day systolic -9.5 (95 % CI 4.1–14.9), p = 0.002; day diastolic -6.4 (95 % CI 2.2–10.7), p = 0.005; night systolic -12.8 (95 % CI 7.8–17.9), p \ 0.000 and night diastolic -8.4 (95 % CI 2.9–13.8), p = 0.004. The reduction in BP was not due to medication titration as the reduction in antihypertensives was not statistically significant (-0.1, p = .67) and there was a statistically significant mean decrease in medication percentage dose of 11.7 % (95 % CI 4.4–19.0), p = 0.03. The analysis suggests that CPAP reduces ambulatory blood pressure readings in patients with OSA and resistant hypertension. Randomised control trials are needed to confirm these results.

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542

S525

Figure 1 Ambulatory blood pressure readings pre and post CPAP Post CPAP, Mean Systolic, 141.7143

Post CPAP, Day Systolic, 144.0000

Post CPAP, Mean Diastolic, 80.3810

Post CPAP, Night Systolic, 136.3333

Post CPAP, Day Diastolic, 83.8095

Post CPAP, Night Diastolic, 76.7143

7.4. Planting the Seed: Introducing Advanced Care Planning Information during Pulmonary Rehabilitation B. Korn, R. Kennedy, M. Scanlan, R. O’Donnell Department of Respiratory Medicine, St. James’s Hospital, Dublin International guidelines [1] recommend Pulmonary Rehabilitation Programmes (PRP) as ideal settings for advanced care planning (ACP) patient education. Despite 10 years of experience delivering PRP, health care professionals (HCP) at our centre have struggled to include ACP sessions into the education programme. Following a literature review, Specialist Palliative Care clinicians delivering ACP sessions at PRPs nationwide were observed and consulted. Experience of ACP with individual patients and formal education were utilised in the development of session content. Sessions follow a structured and standardised programme introducing ACP to patients and relatives. 26 patients and 5 relatives have attended two ACP sessions delivered in May and July 2014. The majority of attendees have welcomed the information, signifying their readiness for the topic. Constructive feedback from attendees continues to shape the content of future sessions. Respiratory CNSs providing the sessions gained confidence and competence in delivering the material. Our experience to date is that patients/relatives are ready for ACP information. However, ACP is an ongoing process in which patients with life limiting illnesses engage with their HCP over time. ACP education sessions at PRP can only plant the seed for meaningful end of life care planning that will affect patient outcomes down the line. Reference: 1. ATS/ERS Statement on Pulmonary Rehabilitation (2013). (Accessed: 11/08/2014). http://www.ers-education.org/lrMedia/ 2013/pdf/234079.pdf

7.5. COPD Satellite Clinic: Does Integrated Care Work For Obstructive Lung Disease? J. Johnstona, P. O’Toolea, J. Gallagherb, B. O’Dohertyc, T.J. Mc Donnella a

COPD Outreach Service and Department of Respiratory Medicine, St. Michael’s Hospital, Dun Laoghaire, Co. Dublin, bThe Palms Surgery, Gorey, Co Wexford, cGorey Medical Centre, Gorey, Co. Wexford

A COPD satellite clinic was established in an attempt to address the under-diagnosis of COPD due in part to a lack of community diagnostic resources [1]. The COPD outreach team attended one of two GP practices on a monthly basis where they provided specialist testing and education for 73 patients who would normally have travelled to a hospital clinic. All patients reviewed by the COPD Outreach team were discussed with the Respiratory Consultant Physician. Forty-eight per cent had their diagnosis confirmed with testing, 21 % received a new diagnosis and 15 % had a respiratory diagnosis excluded. Of those reviewed 34 % had COPD, 31 % had Asthma and 11 % had a mixed COPD/ Asthma presentation. Over 80 % of patients reviewed, benefited from optimisation interventions such as medication recommendations, airway clearance techniques, inhaler techniques or smoking cessation advice. Testing simply confirmed diagnosis in almost half the patients and only five required further investigation or intervention thus highlighting that delivering specialist testing and advice in the community setting could reduce the volume of referrals to hospital based respiratory clinics. This would allow more complex cases to have expedited access to the hospital based investigations and services while routine cases are managed in the community with specialist input when required. References: 1. Jithoo A, Enright P, Burnet P, Buist AS, Bateman ED, Tan WC, et al (2013) Case-finding options for COPD: results from the BOLD Study. Euro Respir J, 41(3): 548–555

7.6. The Acute and Chronic Effects of Dietry Nitrate on Exercise Tolerance in COPD Patients C.P. Kerley1,2, K. Bolger1, K. Cahill1, A. McGowan2, A. O’Brien2, K. Fennell2, J. Faul1,2, L. Cormican1,2 1 Respiratory and Sleep Diagnostics Department, Connolly Hospital, Dublin 15, 2School of Medicine, University College Dublin

Acute consumption of dietary nitrate has been shown to improve exercise capacity in athletes, healthy adults and subjects with peripheral vascular disease. COPD patients have reduced exercise capacity. Acute nitrate consumption might increase incremental shuttle walk test (ISWT) distance in COPD subjects. Eleven COPD subjects were randomly assigned to consume either a high nitrate beverage (beetroot juice, 12.7 mmol nitrate) or a matched low nitrate beverage (\0.5 mmol nitrate) in a double-blind, randomized, placebo-controlled, crossover design. ISWT distance was measured both before and 3 h after the beverage. 7 days later the protocol was repeated with the crossover beverage. Incremental shuttle walk test (ISWT) distance increased after the high nitrate juice (25 m) compared to a reduction after the low nitrate juice (14 m) (p \ 0.01) (Fig. 1). This was associated with significant increases in serum nitrate (p \ 0.000005) and nitrite (p \ 0.01) and a significant lowering of resting blood pressure (\0.05). In a separate, uncontrolled study, we assessed the acute and chronic effect of dietary nitrate on ISWT distance in 6 COPD subjects. We observed an acute increase in ISWT distance (P = 0.02), which was potentiated after 7 days of daily BRJ ingestion (P = 0.006) (Fig. 2).

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Figure 1

Departments of Respiratory Medicine, Cytopathology and Histopathology, Cork University Hospital, Cork

Figure 2

100

600

80

500

ISWT (m)

ISWT (m)

60 40 20

400 300

0

200

-20

100

-40

ΔPL

-60

0

ΔBRJ

Day 1, time 0 Day 1, time 3h Day 8, time 3h

Dietary nitrate appears to hold promise in COPD. We have recently commenced a double-blind, randomized, placebo-controlled crossover trial to assess the value of chronic dietary nitrate in COPD. This work was supported by the Irish Lung Foundation.

7.7. Gremlin1 and Vascular Endothelial Growth Factor Signalling in the Lung S.C. Rowan1, J. Cornwell1, P. McLoughlin1 1

School of Medicine and Medical Sciences, Conway Institute, UCD, Belfield, Dublin 4

Background: Lung cancer screening requires the development of minimally invasive guided bronchoscopy. We describe our initial experience of radial probe ultrasound (rpEBUS) of peripheral lung nodules. Methods: We collected data prospectively of all patients undergoing rpEBUS guided biopsy of peripheral lung nodules over 8 months after MDT discussion. Size, location, FDG avidity, biopsy technique and complications were recorded. Biopsy results were compared to a gold standard composite of confirmatory pathological diagnosis or 6 months clinico-radiological follow up. Results: All thirteen (n = 5 female) patients undergoing rpEBUS under conscious sedation were included (Table 1). The Olympus guide sheath kit was used in 6 patients and brush, biopsy and lavage were taken in most patients (Table 1). The average size of the targeted nodules was 3.5 cm (range 1.8–5.4 cm). A gold standard diagnosis was available thus far in 11 patients. The sensitivity for cancer (n = 4: mean size = 3 cm) was 100 %. We don’t report major complications from the procedure besides minimal bleeding. Only 2/13 patients preceded to surgical biopsy. Conclusion: In our selected small cohort, rpEBUS guided biopsy of peripheral lung lesions is a safe, effective tool in the investigations of peripheral pulmonary lesions. Table 1

7.8. The Use of Radial Probe EBUS in Diagnosis of Peripheral Lung Lesion L. Khorsheed1, K.A. Khan1, J. McCarthy2, L. Burke3, M.T. Henry1, M.P. Kennedy1

case 1 2 3 4 5 6 7 8 9 10 11

target rb4 rb2 rb1 rb1 rb1 rb7 rb3 lb1 rb1 r11 r11

12 13

rb4 rb6

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image mass-like mass mass mass mass mass No mass mass-like mass-like mass mass mass mass

size 2.3cm 1.8cm 3cm 3.5cm 2.5cm 4.4cm 3.2cm 4.3cm 2.3cm 5cm 3cm 2.2cm 2.0cm

brush Y Y N Y Y N Y Y Y Y N

biopsy Y Y Y N Y N Y Y Y Y Y

lavage Y N Y Y Y Y N Y Y Y Y

tbna Y N N Y N Y N N N N N

result Cancer Cancer Cancer Cancer Lymphoma Inflammation Granuloma Inflammation Inflammation Inflammation Inflammation

Y N

Y Y

Y Y

N Y

Inflammation Inflammation

goldstandard Cancer Cancer Cancer Cancer Lymphoma Sarcoid Sarcoid Benign nodule Benign nodule Benign nodule Benign nodule Unknown- awaiting VATS unknown

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7.9. Effect of Cigarette Smoking on Human Pulmonary Immunity During Mycobacterium tuberculosis Infection Seo´nadh M. O’Leary1, Michelle M. Coleman1, Wui Mei Chew1, Colette Morrow2, Anne-Marie McLaughlin3, Mary P. O’Sullivan1, Joseph Keane1,3 1 Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, Dublin, 2Dublin Centre for Clinical Research, St James Hospital, 3Department of Respiratory Medicine, St James Hospital, Dublin, Ireland

Cigarette smoking is linked to important aspects of tuberculosis, such as susceptibility to infection, disease reactivation, mortality, transmission and persistent infectiousness. The mechanistic basis for this remains poorly understood. We sought to compare some immune functions of human alveolar macrophages (AM) from non-smokers, smokers and ex-smokers, after infection with Mycobacterium tuberculosis (Mtb).

S527 Alveolar macrophages (AM) were acquired at bronchoscopy from non-smokers’, smokers and ex-smokers, and AM number and viability were assessed. AM were challenged with Mtb and intracellular bacterial viability was measured. Cytokine secretion was measured 24 h post-infection. The frequency of CD4+FoxP3+ cells in the presence or absence of Mtb-infected and uninfected AM was analysed. AM counts were more numerous from smokers than non-smokers or ex-smokers. AM from smokers could not control intracellular Mtb growth and generated significantly TNF-a and IL-1b compared to non-smokers following Mtb infection. AM taken from ex-smokers also secreted reduced TNF-a and IL-1b after Mtb infection. Both smokers and non-smokers AM induced T regulatory (Treg) phenotype in admixed T-cells, even after Mtb infection. In smokers, the pulmonary compartment has a number of macrophage-specific immune impairments which provide some mechanistic explanations as to the in which cigarette smoking renders a patient susceptible to tuberculosis infection and disease.

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Irish Thoracic Society Poster Review and Discussion Saturday 8th November 2014

8. Lung Cancer Chair

R. Morgan, Beaumont Hospital, Dublin

8.1. Endobronchial Therapy for Central Airway Obstruction under Conscious Sedation A. Subramaniam, K.A. Khan, L.W.Y. Thong, M.T. Henry, M.P. Kennedy Department of Respiratory Medicine, Cork University Hospital, Cork Interventional bronchoscopy is used for relief of central airway obstruction (CAO). The BTS 2011 guidelines recommend this to be done under general anaesthesia. We performed a retrospective review to determine the usefulness and efficacy of endobronchial debulking in patients with CAO and haemoptysis, predominantly in a bronchoscopy suite under conscious sedation. All patients with CAO who underwent endobronchial tumour debulking between March 2013 and August 2014 were included. Patient history, radiological imaging, procedure notes and resultant histology were reviewed. Success was determined based on improvement in clinical symptoms and radiological imaging post intervention. We identified 32 patients (n = 4 indication hemoptysis) with CAO, of which 15 NSCLC, 1 SCLC, 4 carcinoid, 1 granular cell carcinoma, 1 lipoma and 10 other extrathoracic malignancies. 20 were male, mean age was 67 years. All patients had evidence of lung collapse on imaging. 30 patients (94 %) had bronchoscopy under conscious sedation. Therapeutic procedures performed included 24 snare resection, 29 argon plasma coagulation and 1 stenting. 2 patients had repeat procedures. 22 patients (69 %) reported symptomatic improvement on review while 12 patients (38 %) had reaerated airways on post procedure imaging. Endobronchial debulking is an effective adjunct in the management of CAO and can be done under conscious sedation. These interventions can provide symptom palliation and may improve quality of life.

8.2. CT Guided Wire Localisation for Suspicious Pulmonary Lesions: A Review of 7 Patients A. Daly, S. Kilgarrif, D. Eaton, J. Murray, L. Lawlor, K. Redmond Professor Eoin O’Malley National Cardiothoracic and Transplant Unit, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Small pulmonary nodules are increasingly being detected on CT scanning. As many as 50 % of these are related to malignancy.

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Ideally, Video Assisted Thorascopic Surgery (VATS) is performed when excisional biopsy is recommended for diagnosis. This is problematic with deep diffuse nodules, which are difficult to palpate, even with an open approach. We developed a multidisciplinary approach to resection of these nodules in our unit, using CT guided wire localisation and subsequent VATS excision. We report a retrospective case-series of 7 patients who were investigated for small pulmonary nodules using CT guided wire localisation and subsequent resection. Patient demographics, presenting symptoms, lesion characteristics, histological diagnosis and complication rate are reviewed. Radiological and surgical technique are discussed. Mean age of patient was 65.29 years. Median length of stay was 5 days. 42 % of patients had nodules detected incidentally. 28 % of patients were diagnosed with primary pulmonary malignancy. Mean lesion size was 9.8 mm. In one patient, histology failed to locate the suspicious nodule. One patient endured a minor asymptomatic pneumothorax. One patient suffered from acute urinary retention. Overall, CT guided wire localisation is effective. Multidisciplinary input is required. Deep or diffuse nodules are effectively located and thus amenable to VATS resection with this method. Subsequent complication rate is low and relatively minor.

8.3. An Audit of St. Vincent’s University Hospital (SVUH) Rapid Access Lung Cancer (RALC) Pathway 2014 as Part of the National Cancer Control Programme (NCCP) A. Costa Pozza1, J.D. Dodd2, M.W. Butler1, S.C. Donnelly1, M.P. Keane1 1

Department of Med Prof Unit, St.Vincent’s University Hospital, Dublin, 2Department of Radiology, St.Vincent’s University Hospital, Dublin Our aim was to evaluate the SVUH-RALC pathway based on the criteria from the Irish Thoracic Society (ITS) lung cancer guidelines 2009 [1]. It included all patients referred to the pathway between 1st January and 31st March 2014, with a follow-up period of 3 months. Those patients who had a prior thoracic malignancy and had active disease were excluded. Data from 121 patients revealed that 59 had no evidence of lung malignancy, including one who was later referred to the breast cancer pathway with newly diagnosed ductal carcinoma. By the end of the follow-up period, 11 patients lacked formal histology. Two stage IV disease patients had surgery, one due to new M1a disease on the surgical specimen and another with a secondary from an extra-thoracic primary cancer. Of those 11 patients who had thoracic secondaries, the most common histology was adenocarcinoma. The main indication for referral to the pathway was an incidental lung mass, except in those cases of thoracic secondaries where increase in nodule size was the leading reason. The average time delay to be seen in the RALC clinic was 10 ± 7 days. By 30 ± 27 days, all patients had a final plan. 39 patients underwent bronchoscopy, 30 underwent CT guided biopsy and 15 underwent endobronchial ultrasound guided biopsy. Results are in-keeping with ITS recommendation standards.

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Non-small cell Lack Histology

Stage 0

Stage Ia

Stage Ib

Number

11

59

8

5

Males (%)

5 (45.5%)

Age (years)

58.7

64.6

13

Non-smoker (n)

All

2

0

5

2

12

11

2

4

121

2 (100%)

-

2 (40%)

1 (50%)

6 (50%)

6 (54.5%)

1 (50%)

4 (100%)

68 (56.2%)

78.6

68.5

-

64.5

73.4

66.6

58.0

68.5

77.1

64.4

1

0

-

0

0

3

7

0

35 (59.3%) 3 (37.5%) 3 (60%)

61.7

Small cell

Stage IIa Stage IIb Stage IIIa Stage IIIb 1º Stage IV 2º Stage IV Limited Small cell Extended Small cell

5

18

2

2

1

-

2

1

2

Smoker (n)

3

20

2

2

1

-

3

1

4

1

2

48.0

33.3

44.0

34.0

50.0

-

55.0

55.0

35.2

0.6

63.5

100.0

32.3

1.0

0.5

0.8

0.3

0.5

-

0.2

1.3

0.7

0.4

1.0

1.5

0.6

Surgery (n)

0

0

5

2

1

-

3

0

1

1

0

0

13

Curative radiotherapy (n)

0

0

3

3

0

-

1

1

0

0

0

0

8

Chemo +/- radiotherapy (n)

0

0

0

0

2

-

3

1

8

5

2

3

24

Referred to other NCCP pathway (n)

1

1

0

0

0

-

0

0

0

5

0

0

7

Await follow-up CT (n)

2

0

0

0

0

-

0

0

0

0

0

0

2

Palliative (n)

4

0

0

0

0

-

0

0

0

0

0

0

4

Mortality (n)

3

0

0

0

0

-

0

0

5

0

0

1

9

Smoking Hx (pack-year)

Performance Status (mean)

ii

References: 1. Irish Thoracic Society Guidelines for the diagnosis and treatment of lung cancer. Irish Thoracic society lung cancer sub committee 3rd ed. ITS; 2009 2. Oken MM, Creech RH, Tormey DC et al (1935) Toxicity and response criteria of the Eastern cooperative oncology group. Am J Clin Oncol, 5 (6): 649–655

8.4. A Retrospective Review of Outcomes in Patients Referred for EBUS in Tallaght Hospital in a 1 Year Period

0

24

Ex-smoker (n)

2

35 39

The results identifies the high volume of EBUS referrals from AMNCH for lung cancer staging procedures but also reflects the increasing potential of EBUS as a diagnostic tool for benign lung pathology such as infection and sarcoidosis. References: 1. Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET/CT in mediastinal staging of potentially operable non-small cell Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, Kim HY, Lee GK, Nam BH, Zo JI S Chest. 2009;135(5):1280. 2. Nakajima T, Yasufuku K, Kurosu K, et al (2009) The role of EBUS-TBNA for the diagnosis of sarcoidosis-comparisons with other bronchoscopic diagnostic modalities. Respir Med 103:1796.

D. Ryan, R. Cusack, S.J. Lane, E. Moloney Adelaide and Meath Hospital, Incorporating the National Children’s Hospital (AMNCH), Tallaght EBUS TBNA is the preferred first line method for staging NSCLC in patients with anterior mediastinal or hilar lymph nodes on CT scan or PET [1]. Accuracy of staging is important for management and prognosis. EBUS also has an increasingly important role in the diagnosis of benign pathology such as sarcoidosis and infection [2]. In this study we examine the staging results of patients referred from AMNCH to a national cancer centre of excellence (St James) over the past year. Between July 2013 and July 2014 a total of n = 45 patients were referred for EBUS procedure in St James Hospital from AMNCH. Of these n = 20 were referred for staging of NSCLC in patients who already had a tissue diagnosis from bronchoscopy or CT guided biopsy. n = 21 patients had a negative EBUS result without a subsequent diagnosis of malignancy and n = 4 were positive for non caseating granuloma suggestive of sarcoidosis. STAGING

No of patients (N = 18)

IA

4

IB

2

IIA

3

IIB

1

IIIA IIIB

5 3

IV

2

8.5. Endobronchial Ultrasound Guided Trans-bronchial Needle Aspiration for the Diagnosis of Lung and Mediastinal Lesions: Audit of Service D.J. McCracken, G. Loye, T.E. McManus Department of Respiratory Medicine, South West Acute Hospital, Enniskillen Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is recommended by the National Institute for Health and Care Excellence (NICE) for the investigation of mediastinal, paratracheal and peribronchial lesions suspicious of malignancy and has significant benefits over traditional mediastinoscopy. The service was introduced in the South West Acute Hospital in October 2012 and was the first unit in the province to offer it. A prospective audit was conducted on all cases performed in the first 17 months since the service’s inception and sensitivity and specificity data compared with that published by other centres across Europe. Sixty-four patients had complete follow-up data with seventy-five tissue samples obtained. The most common stations for tissue sampling were recorded. Pathological cells were found in 47 cases and diagnoses recorded with primary lung tumours making up the majority. Diagnostic sensitivity was calculated as 81 % and specificity 100 % which is similar to published data. Clear benefits in the diagnosis of lung carcinoma and mediastinal adenopathy were demonstrated with results showing comparable

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sensitivity and specificity to other centres. Results suggest increasing number of samples improves diagnostic yield and that the procedure is sufficient for the diagnosis of lymphoma. Sustainability demonstrated with plans to expand service and facilitate training. Reference: Yasufuku K et al (2011) A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 142(6):1393–1400

(n = 8) of patients were mobilised away from the bedside within 24 h of surgery. This increased to 48 % (n = 25) of patients within 36 h of surgery. The main reasons patients did not mobilise day one postsurgery were due to a wall suction attachment (46.43 %), low blood pressure (42.86 %), drowsiness (3.58 %) and pain (4.54 %). By 72 h post-surgery 73 % of patients were mobilising away from the bedside. A number of barriers prevent patients from mobilising away from the bedside in the first three days post thoracic surgery. Efforts must now be made to reduce these barriers.

8.6. Use of PleureX Catheter Drains in the Management of Recurrent Pleural Effusions

8.8. The Design and Validation of a Novel Lung Navigation Platform

L. McGrath-Soo, N. Abbas, A. Bates, K.A. Redmond, D. Healy, D. Eaton

K.A. Khan, K. O’Donoghue, P. Nardelli, J. Tugwell, C. O’Shea, P Cantillon-Murphy, M.P. Kennedy

Departments of Thoracic Surgery Mater Misericordiae University Hospital and St Vincent’s Hospital, Dublin We report on our experience of using the indwelling PleureX catheter drainage system for the management of patients with treatmentresistant recurrent pleural effusions. The PleureX device consists of a thin (5 mm) silicone drain, the distal end is placed in the pleural space. There is a polyester cuff which is placed via a subcutaneous tunnel 2 cm from the skin surface securing the drain by encouraging tissue ingrowth whilst the subcutaneous tunnel can either reduces fluid leakage and infection risk. The drainage system a vacuum bottle intermittently attached to control the drainage at home. We report our experience of 43 patients who have had a PleureX drainage systems inserted over the last 22 months period. The majority were carried out under local anesthetic. Most patients had rapid relief of their symptoms with low infection rates, the majority subsequently had spontaneous pleuradhesis and had their drainage system removed in outpatients. Recurrent pleural effusions are a common debilitating complication of advanced cancer. The PleureX system is ideally suited to the management of these patients, being simple to insert, safe and effective and easily managed at home. Improving patient’s quality of life by reducing hospital admissions and allowing them to be managed at home.

Tissue acquisition of peripheral lung lesions remains a challenge. We have developed a 3D electromagnetic navigation platform with airway segmentation and virtual bronchoscopy in the open source 3D slicer environment. The 3D Slicer software was used to create a detailed airway segmentation and virtual bronchoscopy model from CT images. A magnetic field emitter board provides tracking of a locatable sensor probe in the working channel of the bronchoscope. A breathing lung simulator mimicking actual bronchoscopy environment was developed using inflatable plasticized pig lungs in a negative-pressure chamber with the trachea connected to atmospheric pressure allowing bronchoscope insertion. The breathing lung model may also be programmed for sporadic disturbances (e.g. cough) as well as variability in ‘‘respiration’’ through the rate and length of inflation and deflation. CT images of the plasticized pig lung were used to create a virtual airway segmentation model. Bronchoscopic navigation containing the sensor probe was performed on the model, under both static and cyclical inflation. The navigational system accurately determined 89.3 % of the navigation points within the main airways. Our navigational platform is inexpensive and open source. In our porcine lung model, there is good agreement between the position of the sensor probe during bronchoscopic navigation and as visualised in virtual bronchoscopy. Further work is being performed to improve the accuracy of the navigational system and a pilot study in patients with peripheral lung nodules.

8.7. Barriers to Mobilising Patients Post Thoracic Surgery

8.9. A Review of Pre Admission Clinics for Lung Cancer Patients Requiring Surgery

G. Sheill1, K. Devenney1, M. Spain1

M. Fitzgerald, R. Ryan

Physiotherapy Department, St James’s Hospital, Dublin

Keith Shaw Cardiothoracic Unit, St. James’s Hospital, Dublin 8

It is documented that post-operative management of thoracic patients should focus on early mobilisation to reduce pulmonary complications. Little is known about the barriers which may prevent mobilisation after thoracic surgery. It is important to identify and reduce these barriers to ensure the highest levels of activity possible in this patient group. This was a prospective, observational cohort study. Consecutive post-surgical thoracic patients in a national cardio-thoracic centre were monitored for 3 days post-operatively. Information was recorded on a prospectively developed database by treating physiotherapists. Fifty-two patients were monitored post-surgery (Male = 29 Female = 23). The average length of stay was 9.63 days. 15 %

St. James’s Hospital is a national referral centre for lung cancer patients and in 2011 50 % of the national surgical resections were performed in St. James’s Hospital. As part of a multidisciplinary review of patient care it was decided to set up a pre admission clinic for lung cancer patients coming for elective surgical resection. This review was carried out over a 6 month period in 2014 comparing the pathway for patients that attend pre-admission clinic to those that remain on the original pathway. In the 6 month period, 135 Lung resections were performed and 30 of them attended the pre admission clinic. Those that attended the clinic were educated regarding physiotherapy; the majority of them consented for bio-banking, patients were discussed with an anaesthetist and reviewed if required,

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and some were referred to smoking cessation, they had MRSA screens and routine bloods completed. We compared the length of stay for both groups of patients and reviewed the rate of postoperative complications.

8.10. Sputum Cytology as a Valuable Diagnostic Modality in Patients with Advanced Lung Neoplasia O. O’Brien1, C. Ryan1, D. Fitzgerald2, T.J. Browne1, J. McCarthy1 1

Department of Histopathology, Cork University Hospital, Department of Respiratory Medicine, Cork University Hospital

2

Sputum sampling is a quick, cheap and non-invasive diagnostic technique now most commonly used in respiratory medicine to aid the diagnosis of respiratory infections. Its value in diagnosing lung carcinoma is hampered by poor sensitivity and is rarely used in this era of bronchoscopy. We aim to assess the potential to utilise sputum cytology in the diagnosis of lung neoplasia, and determine if the sensitivity relates to tumour stage or cytological subtype. A prospective analysis of all sputum samples sent for cytologic evaluation between 1st January 2012 and 31st December 2013 was performed. The cytologic diagnosis was correlated with final patient outcome. Table 1: Cytologic diagnostic categories of sputum samples C5 C4 C3 C2 Total Malignant Suspicious Atypical Benign Outcome malignant

27

8

10

15

60

Outcome benign

0

2

6

49

57

Total

27

10

16

64

117

The search identified 117 sputum samples from 95 patients. The positive predictive value of sputum cytology per category was 100 % (C5, malignant), 80 % (C4, suspicious) and 62.6 % (C3, atypical). Sputum cytology had a false positive rate of 0 %. The false negative rate was 25 %. The complete sensitivity and specificity of sputum cytology were 75 and 86 % respectively. Of the patients who had malignant cytology (C5), 89 % had stage 3/4 disease. Of malignant sputum specimens (C5), 51.9 % were squamous cell carcinoma, 40.7 % adenocarcinoma and 7.4 % of cases were small cell carcinoma. In conclusion, sputum cytology can be of benefit in obtaining a diagnosis of lung neoplasia via a non-invasive route, particularly in patients with advanced disease who may be unable to tolerate an invasive procedure.

8.11. Should Maximal Oxygen Consumption (VO2 max) be used as an Indicator in the Assessment of Patients for Lung Cancer Surgery Rather than a Percent Predicted Gas Diffusion Value (DLCO)?

Lung cancer is a fatal disease with high mortality and poor survival rates. Surgical intervention provides the only curative treatment currently available for the disease and the need for pre-operative assessment is crucial. The diffusion of lung carbon monoxide (DLco) from a pulmonary function test (PFT) and maximal oxygen uptake (VO2 max) from cardiopulmonary exercise testing (CPET) are the main parameters which govern surgical suitability. There have been numerous articles published in relation to the preoperative assessment of DLco and CPET in patients presenting for lung cancer surgery. The purpose of this study was to investigate the significance of CPET rather than using DLco in the pre-operative assessment for surgery of patients with lung cancer. The hypothesis of the project was that a patient may still be eligible for surgery using VO2 max as a clinical indicator rather than DLco. Findings: • •

Surgical eligibility rose by 25 % using VO2 Max value rather than DLco value (increase from 9/16 to 13/16 patients) Potentially patients are being denied surgery on DLco value alone.

Awareness of this topic is critical as only 50 % of the rapid access lung cancer centres (RALCC) in Ireland carry out CPET. Should CPET be made more readily available?

8.12. Review of Lung Cancer Reporting Standards in a District General Hospital D. Jackson, R.A. Sharkey, M. Doherty, M. Mc Closkey, M. Kelly, T. Mc Manus, A. Aziz, D.M. Campbell Radiology and Respiratory Departments, Western Trust, N Ireland Chest X-ray (CXR) is a first line investigation for suspected lung cancer and the current Royal College of Radiologists (RCR) standards are that in patients with proven lung cancer, the lesion should be identified in C75 % of CXRs done within 1 year of the diagnosis and when a CXR lesion is reported, further investigation should be recommended in [ 95 % of cases. The CXRs of all patients diagnosed with lung cancer in 2013, were reviewed by a consultant radiologist. The CXR abnormality was identified in 82 % of cases (standard C75 %). In patients found to have an abnormality on CXR, further investigation was advised by radiologist in 77 % of cases (standard = 99 %). The identification of abnormality on CXR was within the recommended standard. Radiologist’s advice regarding further investigation was below standard. These results have been presented to all radiologists within our department to re-inforce the RCR recommendations and a re-audit will take place to confirm improvement in the standards.

8.13. Pleural Procedure Pro Forma: a Quality Enhancement Project

S. Cox, M. Mc Neill, O. Farrelly, E. O’Rourke, M. Sheehy

S.A. Landers, L.J. Chawke, R.P. Cusack, D.R. Curran, T.M. O’ Connor

Respiratory and Sleep Diagnostics Department, Midlands Regional Hospital, Mullingar, Co Westmeath

Department of Respiratory Medicine, Mercy University Hospital, Cork

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S532 Pleural disease affects approximately 3,000 people per million of the population per year and therefore represents a significant clinical responsibility for the respiratory physician. The British Thoracic Society (BTS) developed guidelines for the investigation and management of pleural disease in 2010. The aim of our audit was to identify current documentation practices of pleural procedures within our respiratory department and to determine procedure adherence to the BTS guidelines. In addition, we sought to develop a pro forma to improve the quality of documentation of pleural procedures. The audit population included patients who underwent a pleural procedure over three consecutive months from August to October 2013 (n = 22) and again from April to June 2014 (n = 16) following introduction of the pro forma. Written informed consent, haematological parameters and Light’s criteria were each documented in 100 % of cases following implementation of the pleural procedure pro forma, versus 13.6, 54 and 70 % of cases, respectively, prior to its implementation. Our audit therefore concludes that a pleural procedure pro forma is an appropriate intervention to improve quality of care for patients with pleural disease in line with the BTS guidelines and to facilitate efficient retrieval of pleural procedure results.

8.14. Endobronchial Cryotherapy in the Management and Palliation of Benign and Malignant Airway Disease S. Ryan, D. Eaton, K.A. Redmond Department of Thoracic Surgery, Mater Misericordiae University Hospital, Dublin

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 In keeping with international trends, the incidence and mortality of patients presenting with advanced airway disease, both benign and malignant, are increasing among the Irish population with many patients presenting with advanced disease that excludes the potential for curative management. Consequently palliative treatment options for this patient group are being increasingly explored with various degrees of success. Endobronchial stenosis represents a particularly challenging area of management among these patients. It commonly presents with distressing symptoms associated with airway obstruction, including stridor, dyspnoea and haemoptysis. Appropriate management of these patients is aimed at providing rapid and effective palliation to prevent the significant morbidity associated with occlusion of a major airway. The last 3 years have seen an exponential increase in both the number of referrals to the Mater Thoracic unit for the treatment of cryotherapy and the number of cryotherapy procedures performed in the management of benign and malignant airway disease. Our experience has shown that with prompt referral and intervention, endoluminal cryotherapy can be performed safely with few complications allowing maximum improvement in both symptoms and quality of life in advanced airway disease.

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Irish Thoracic Society Poster Review and Discussion Saturday 8th November 2014 9. COPD Basic Science Chair

M. Butler, St Vincent’s University Hospital, Dublin

9.1. Altered Membrane Cholesterol Content Contributes to the Dysregulated Activity of Neutrophils in Alpha-1 Antitrypsin Deficiency B. Jundi, M. White, N. Lacey, N.G. McElvaney, E.P. Reeves Department of Medicine, Respiratory Research, Beaumont Hospital, RCSI, Dublin 9 Individuals with alpha-1 antitrypsin (AAT) deficiency (AATD) are predisposed to early-onset emphysema and neutrophils are the primary effector cells responsible for the pathological manifestations of AATD lung disease. As AAT interacts directly with the circulating neutrophil membrane [1], the question that this project addressed was: are AATD neutrophils structurally and functionally altered? The aim of this study was to explore a link between disrupted membrane structures and impaired trafficking of cholesterol in AATD neutrophils. Circulating neutrophils were purified from blood of patients with AATD and from healthy control individuals (n = 7). Membranes and cytosols were isolated from neutrophils by sucrose-gradient ultracentrifugation. Cholesterol and calcium levels were fluorometric quantified and calpain levels measured using a calpain activity assay. Caveolin-1 expression was examined by Western blot analysis. Statistical comparisons were performed by Student’s t test. Neutrophil cytosols of AATD individuals had increased calcium concentrations (n = 7, p = 0.04) and activation of the calcium dependent protease calpain (n = 7, p = 0.01). Furthermore, levels of the cholesterol trafficking protein caveolin-1 were significantly lower in AATD neutrophil cytosols (n = 6, p = 0.01) leading to significantly decreased membrane cholesterol content when compared to healthy control cells (n = 5, P = 0.045). In summary, our findings have demonstrated for the first time increased calcium, increased calpain activity causing proteolytic cleavage of caveolin-1, and decreased membrane cholesterol content of AATD neutrophils. This novel data may in part explain the dysregulated activity of this innate immune cell in AATD. Reference: 1 Bergin, DA et al. alpha-1 Antitrypsin regulates human neutrophil chemotaxis induced by soluble immune complexes and IL-8. J Clin Invest 120, 4236–4250

9.2. Examining Diffusing Capacity (DLCO) and Functional Impairment in a Population of ZZ AATD Individuals B. Murray, T.P. Carroll, L.T. Fee, E. O’Brien, C. O’Connor, C. Egan, L. Clarke, N.G. McElvaney Alpha One Foundation, RCSI Smurfit Building, Beaumont Hospital, Dublin Alpha-1 antitrypsin deficiency (AATD) is a genetically inherited condition, which often presents with COPD. Little evidence exists of

S533 the impact of ZZ AATD on the diffusing capacity of the lung for carbon monoxide (DLCO), and its relationship with functional exercise impairment has never been examined among the Irish population of ZZ AATD individuals. We analysed data from 128 PiZZ homozygous individuals enrolled in the National AATD Registry. Pulmonary function test results were assessed for DLCO and compared to smoking status and pack year histories. 6 min walk test (6MWT) information was collected for individuals with a decreased DLCO to measure functional exercise impairment. In this group the mean FEV1 % predicted was 60.5 ± 32.1 and the mean %predicted DLCO was 54.9 ± 24.2. The mean values for active and past smokers were both lower than those for never smokers. Patients who had a 6MWT had a mean %predicted distance of 62.4 ± 16.7 and portable oxygen was indicated in 65 %. DLCO is impaired in this group of ZZ AATD individuals and smoking history further reduces the DLCO when compared with never smoking ZZ AATD individuals. Functional impairment was present in 65 % of individuals with impaired DLCO.

9.3. Identification of Novel Truncated Alpha-1 Antitrypsin in a QBT-AAT Deficient Patient C.A. O’ Dwyer, Cormac McCarthy, R. Fahey, D.A. Bergin, M. Henry, T. Carroll, P. Meleady, J. Keenan, M. Clynes, P. Rudd, E.P. Reeves, N.G. McElvaney Department of medicine, Beaumont Hospital, RCSI and National institute for cellular biotechnology, DCU Alpha-1 antitrypsin (AAT) is the most abundant circulating protease inhibitor and its major physiological role is to protect the lung from the destructive effects of neutrophil elastase. AAT deficiency (AATD) is associated with early onset emphysema, COPD and liver disease. Of particular interest are the class of rare AAT mutations, called null mutations arising from introduction a premature stop codon. This leads to no detectable serum AAT by routine methods such as nephlometry and isoelectric focusing (IEF). The aim of this study was to purify AAT from plasma of a homozygous null patient using Alpha-1 Select Resin and to characterise the truncated protein in terms of proteomics and glycosylation. Plasma samples were collected from control individuals homozygous for the M allele (normal AAT) and an AATD patient homozygous for the null Bolton allele (QBT-AAT). AAT was purified from plasma using Alpha-1 chromographic Select Resin (GE Healthcare). SDS-PAGE, Western blot analysis and mass spectrometry was performed on purified AAT. Glycoanalysis was performed employing N-glycan release, exoglycosidase digestion and UPLC analysis. Utilising the Alpha-1 Select Resin we purified a low molecular weight protein of approximately 48 kDa from the plasma of the QBTAAT individual compared to the 52 kDa native AAT protein from healthy controls. A significant increase in both outer arm and core fucosylated glycans (P = 0.003) was found in the QBT-AAT compared to the M-AAT as well as increased Tri-antennary (P = 0.0008) and tetra-antennary (P = 0.017) branching. This is the first ever documentation of the presence of AAT protein in plasma of a null AATD patient. The altered glycosylation of the QBT-AAT protein is indicative of chronic inflammation and highlights the need for therapeutic intervention in these individuals. Funding: This study was funded by the US Alpha-1 foundation.

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9.4. Examination of CXCL11 and CXCR3 Expression in the Lung in Response to Hypoxia Clare Hughes, Myles Paterson, Paul McLoughlin, Christine Costello

Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 (SD 26.3). 8 patients had CKD stage 3 (defined as eGFR \ 60 ml/ min/1.73 m2) and no patient had stage 4 or 5 disease. There was a positive correlation between annual change in eGFR and FEV1 (r = 0.384, r2 = 0.148, n = 28, p = 0.043). Our study suggests that GFR correlates with the severity of airflow obstruction.

UCD Conway Institute, School of Medicine and Medical Science, UCD, Dublin 4 Pulmonary hypoxia may lead to the development of pulmonary hypertension, a disease characterised by abnormal vascular remodelling. We recently discovered that expression of the angiostatic CXCL11 receptor, CXCR7, was selectively upregulated in the murine lung in response to hypoxia. Here we investigate the expression pattern of CXCL11, and its second receptor, CXCR3, in the lung in response to hypoxia. Adult male C57BL/6 mice were housed in normoxia (n = 9; 21 % O2) or hypoxia (n = 8; 10 % O2 for 48 h) and gene expression examined by western-blotting and immunohistochemistry. Quantification of CXCL11 expression was carried out by stereology using a computer-based analysis system (CAST, Visiopharm) combined with light microscopy. RT-PCR experiments examined CXCL11 and CXCR3 expression in human pulmonary microvascular endothelial cells (HMVEC-L) maintained in normoxia or hypoxia (1 % O2). Immunohistochemical analysis showed that CXCL11 was expressed on infiltrating cells, erythrocytes, pulmonary epithelium and endothelium. Western-blotting demonstrated that CXCL11 expression was significantly upregulated in response to hypoxia (p \ 0.05) in mouse lungs (n = 5/group). CXCL11 expression in HMVEC-L decreased with hypoxic exposure whereas CXCR3 levels increased. Our preliminary data suggests that the CXCL11/CXCR3 biological axis is differentially regulated in response to hypoxia. Further experiments will establish the role of this pathway in hypoxic pulmonary vascular disease.

9.5. Chronic Kidney Disease with Chronic Obstructive Pulmonary Disease: Decline in Forced Expiratory Volume Correlates with Loss of Glomerular Filtration Rate D.M. Kelly, E.A. Galbraith, W. Plant, D.M. Murphy Departments of Renal and Respiratory Medicine, Cork University Hospital, Cork, Ireland COPD is associated with increased risk of renal failure. Chronic kidney disease (CKD) is under-recognized in this population and microalbuminura is a risk factor for overall mortality. We aimed to determine any relationship between FEV1 and GFR by conducting a retrospective review of oxygen-dependent COPD patients attending the service in Cork University Hospital. Thirty-eight patients on long-term oxygen therapy for mean 2.3 years (SD 1.9 years) were identified and serum creatinine, estimated GFR (eGFR), spirometry, medications, heart function and annual exacerbation frequency documented. eGFR was calculated using the Modification of Diet in Renal Disease formula. The mean age of the group was 72.16 years (SD 7.48 years) and mean FEV1 was 49.7 % predicted (SD 21.3 %). 13.2 % were diabetic and 21 % had known ischaemic heart disease. 34.3 % had 3 or more exacerbations per year. The mean current eGFR was 80.05 ml/min/1.73 m2

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9.6. Cross Talk Between the Bone Morphogenetic Antagonists and Wnts in the Pathogenesis of Chronic Lung Disease Joanna Cornwell, Simon Rowan, Paul McLoughlin School of Medicine and Medical Sciences, Conway Institute, UCD

9.7. Erythropoietin (EPO)/b-Common Receptor (b-CR) Signalling: A Potential Therapeutic Role in Lung Disease? Keith Rochfort1, Philip Lewis1, Katie Thursfield1, Elaine Coleman1, Katherine Howell1 1

School of Medicine and Medical Science, Conway Institute, UCD, Belfield, Dublin 4, Dublin

9.8. The Alpha-1 Antitrypsin Deficiency National Targeted Detection Programme L. Fee, T.P. Carroll, C. O’Connor, P. Ryan, P.O’Brien1, E. Pentony, I. Ferrarotti2, S. Ottaviani2, M. Luisetti2, and N. G. McElvaney Alpha One Foundation, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9. 1Department of Biochemistry, Beaumont Hospital, Dublin 9, 2Department of Biochemistry and Clinical Genetics, University of Pavia, Italy AAT deficiency (AATD) is a hereditary disorder resulting from mutations in the SERPINA1 gene, classically presenting with earlyonset emphysema and/or liver disease. The most common mutation causing AATD is the Z mutation, with the S mutation weakly associated with lung disease. AAT deficiency is under-diagnosed and prolonged delays in diagnosis are common. ATS/ERS guidelines advocate screening all COPD, poorly-controlled asthma, and cryptogenic liver disease patients, as well as first degree relatives of known AATD patients. Over 12,500 individuals have been screened to date following ATS/ERS guidelines in the national targeted detection programme. Sequencing of the SERPINA1 gene was performed to identify rare mutations. We have identified 228 ZZ, 180 SZ, 66 SS, 1764 MZ, 1274 MS, and over 178 individuals with rare phenotypes (e.g. IZ, FZ, IS, Null, Mmalton). A number of novel SERPINA1 mutations have also been identified. Of all samples tested to date 30 % carry at least 1 AAT mutation. Our results illustrate the high prevalence of AATD in Ireland with our data demonstrating that AATD in Ireland is not a rare disease but a disease that is rarely diagnosed. We advocate that all COPD patients should be tested for AATD as per ATS/ERS guidelines.

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9.9. Circulating Levels of Neutrophil Elastase and Markers of Platelet Activation are Increased in Alpha-1 Antitrypsin Deficient Patients N. Lacey, M.E. O’Brien, N.G. McElvaney, E.P. Reeves Respiratory Research Division, Royal College of Surgeons in Ireland Alpha-1 antitrypsin (AAT) is a key inhibitor of destructive neutrophil derived proteases, functioning to maintain a homeostatic proteaseantiprotease balance. AAT deficiency results in different pathological consequences, lung disease being the most intensively studied. Studies are lacking on the systemic effect of reduced circulating AAT. For this reason we evaluated circulating levels of neutrophil proteases in AAT deficient patients and platelet activation markers compared to healthy subjects. Whole blood was obtained from AAT deficient homozygous phenotypes (ZZ, n = 11) not receiving treatment, ZZ patients on AAT augmentation therapy (n = 6) and healthy subjects (n = 9). Platelet rich and platelet poor plasma samples were analysed. Neutrophil elastase (NE) activity was measured by spectrofluorescent analysis using a specific substrate. Markers of platelet activation were quantified by ELISA. Statistical significance was determined by ANOVA. Plasma levels of NE were increased in ZZ patients compared to healthy subjects (p = 0.011). All markers of platelet activation including sp-Selectin, CCL5, GPV were significantly increased in ZZ patients (P \ 0.05), with levels normalised in patients receiving weekly AAT augmentation therapy infusions (60 mg/kg of patient body weight). These results indicate that neutrophil-platelet activation triggered by circulating levels of proteolytically active NE may mediate thrombosis and vascular inflammation in individuals with AAT deficiency. AAT augmentation therapy provides a homeostatic mechanism that maintains circulating platelets in a resting state.

9.10. Neutrophils of Individuals with Alpha-1 Antitrypsin Deficiency Homozygous for the Z Allele Release Enhanced Levels of Primary, Secondary and Tertiary Granule Components S.A. Landers, F.S. Gargoum, K. Pohl, E.P. Reeves, N.G. McElvaney Respiratory Research Division, Department of Medicine, Royal College of Surgeons of Ireland Education and Research Centre, Beaumont Hospital, Dublin 9 Alpha 1 antitrypsin deficiency (AATD) is the most common genetic cause of pulmonary emphysema, with 1 in 2,104 individuals homozygous for the Z allele in Ireland. Dysregulated neutrophil degranulation is recognised as an important event in inflammatory conditions such as COPD. Initial studies have demonstrated that the incidence of autoantibodies directed against neutrophil degranulated proteins is increased in AATD [1]. The aim of this study was to investigate whether neutrophils of AATD individuals release enhanced levels of primary, secondary and tertiary granule components. Circulating neutrophils were isolated from both ZZ-AATD individuals and healthy controls (n = 6). Degranulation assays were performed in response to PMA, TNF-alpha and fMLP. Levels of extracellular degranulated proteins were measured by Western blot analysis. Our results demonstrate that ZZ-AATD neutrophils degranulate increased levels of elastase, lactoferrin and matrix-metalloprotease-9

S535 (p \ 0.05), markers of primary, secondary and tertiary granules, respectively. The molecular basis for this enhanced degranulation involving activation of the GTP-binding proteins Rac2 and Rab27a in ZZ-AATD is being explored. In summary, our study has identified enhanced neutrophil degranulation as a potential parameter of disease progression in AATD. We hypothesise that AAT augmentation therapy may normalize neutrophil Rac2 and Rab27a activation therapy thereby reducing inflammation in patients with AATD. Reference: 1. Bergin DA et al (2014) The circulating proteinase inhibitor alpha-1 antitrypsin regulates neutrophil degranulation and autoimmunity. Sci Transl Med 6, 217ra211

9.11. Rare Alpha-1 Antitrypsin Mutations in the Irish Population T.P. Carroll1, L. Fee1, C. O’Connor1, P. Ryan1, P.O’Brien2, E. Pentony2, I. Ferrarotti3, S. Ottaviani3, W. Tormey2, M. Luisetti3, N.G. McElvaney1 1

Alpha One Foundation, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9, 2Department of Biochemistry, Beaumont Hospital, Dublin 9, 3Department of Biochemistry and Clinical Genetics, University of Pavia, Italy AAT deficiency (AATD) results from mutations in the AAT gene, classically presenting with chronic obstructive pulmonary disease (COPD) and liver disease. The most common disease-causing mutation is Z (Glu342Lys), with the milder S (Glu264Val) also associated with lung disease. AATD is under-diagnosed and prolonged delays in diagnosis are common. ATS/ERS guidelines advocate screening all COPD, refractory asthma, and cryptogenic liver disease cases, as well as relatives of AATD individuals. Over 12,000 individuals were screened following ATS/ERS guidelines as part of a national AATD targeted detection programme. AAT quantification is by turbidimetry and AAT phenotyping is by isoelectric focusing. Suspected rare mutations are identified by DNA sequencing. We identified a large number of rare AAT mutations including the pathological I, F, null (Q0), Mmalton, Mwurzburg, and Zbristol. The I mutation (Arg39Cys) is most common with 109 cases identified, while the F mutation (Arg223Cys) occurs in 42 cases. These two mutations account for 85 % of all rare mutations detected. In addition, 7 novel mutations were identified, including the novel null mutations Q0dublin and Q0cork. Rare mutations were detected in 1.5 % of individuals screened. Our findings underline the need for a comprehensive diagnostic work up of low AAT levels including phenotyping, genotyping and if necessary, DNA sequencing.

9.12. Beetroot Supplementation in Patients Undergoing Pulmonary Rehabilitation: Results of the Northern Trust Beetroot Breathlessness Study AJ. Boyle1, R, Donnelly1, E. Murtagh1, J. Leggett1, M. Stephenson2, W. Anderson1 1

Department of Respiratory Medicine, Antrim Area Hospital, Antrim, Dept of Medical Statistics, Centre for Public Health, Queen’s University Belfast

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Patients with COPD, and other exercise-limiting respiratory disorders, may benefit from a short course of pulmonary rehabilitation to maximise their exercise capacity. Novel research in competitive cyclists has found that supplementation with beetroot juice enhanced their exercise capacity, whilst similar findings have been found in swimmers. As yet there has been no investigation of dietary nitrate supplementation in a chronic respiratory disease population. We performed a small crossover trial to investigate the effect of beetroot supplementation upon performance in pulmonary rehabilitation patients. Ten patients were recruited and asked to drink 500ml of Beetroot juice, or Ribena juice, in the 24 hour period prior to commencing the class, on alternate weeks for six weeks. Outcomes measured include distance walked, SaO2, and BORG score. Beetroot juice supplementation was associated with a trend towards improved distance walked, with 7 of 10 patients showing improved mean distance walked during the weeks they consumed beetroot (p = 0.07). These findings, although preliminary and subject to further analysis, suggest there may be merit in larger trials investigating the use of dietary nitrate supplementation in patients with reduced exercise capacity as a result of chronic respiratory disorders.

Irish Thoracic Society Poster Review and Discussion Saturday 8th November 2014

10. Tuberculosis and Other Infections Chair

J. Keane, St James’s Hospital, Dublin

10.1. The prevalence of Chronic Obstructive Pulmonary Disease in Patients with Culture-Confirmed Pulmonary Tuberculosis

In this cohort, the prevalence of COPD among males with pulmonary TB was high and significantly higher than females. Further research is needed prospectively to examine the association of COPD and TB in the Irish population.

10.2. A Liver-Friendly Regimen for Drug-Sensitive TB D. Watchorn, M. Higgins, C. MacMahon, C. McDonald, J. Keane, A. McLaughlin Department of Respiratory Medicine, St James’s Hospital, Dublin 8, Ireland Guidelines recommend modification of drug-sensitive TB treatment in patients with ALT elevation more than three times the upper limit of normal (ULN) with hepatitis symptoms, or five times the ULN without symptoms [1]. We describe experience with the ‘liverfriendly’ regimen: Moxifloxacin, Amikacin and Ethambutol. One patient with breast cancer was undergoing Vinorelbine (metabolised by CYP3A4) treatment when diagnosed with pulmonary TB. Isoniazid was discontinued after an idiosyncratic reaction and transaminases became deranged above five times the ULN on pyrazinamide. Radiographic resolution occurred after a 6 month ‘liverfriendly’ regimen. One patient diagnosed with pulmonary TB had elevated transaminases—attributed to Voriconazole (subsequently stopped). After 10 days’ treatment with Moxifloxacin, Amikacin and Ethambutol, improving LFTs permitted introduction of first-line therapy. A patient with urinary tract TB developed a hypersensitivity reaction to Rifampicin and deranged LFTs on Pyrazinamide. Irritative urinary symptoms persisted after 1 month of the liver-friendly regimen. Worsening renal indices mandated discontinuation of amikacin and isoniazid was reintroduced. Rechallenge with escalated dosing of rifampicin was tolerated, with symptomatic resolution and negative urine TB cultures after 6 months’ treatment. This case series highlights the need for systematic testing of alternative treatment regimens for patients at risk of TB drug-induced liver injury. Reference: 1. Saukkonen JJ et al (2006) An official ATS statement: hepatotoxicity of antituberculosis therapy. Am J Respir Crit Care Med. 174(8):935–952

B. O’Connor, T.M. O’Connor Department of Respiratory Medicine, Mercy University Hospital, Cork, Ireland Tuberculosis (TB) and chronic obstructive pulmonary disease (COPD) are major causes of mortality and morbidity. These diseases have shared risk factors such as smoking, low socioeconomic status and genetic predisposition. The aim of the study was to examine (1) prevalence of COPD in culture confirmed pulmonary TB, (2) to assess if gender, age, tobacco use and alcohol have an impact on the diagnosis of TB. We performed a retrospective descriptive study of patients referred to Mercy University Hospital, Cork from 2006 to 2012 who had culture-confirmed pulmonary tuberculosis. One hundred and forty two subjects were studied. Of these, 70.4 % (100) were male and 29.6 % (42) female; 78.2 % (111) were Irish and 21.8 % (31) foreign-born. The mean age at diagnosis was 43 years for males and 29 years for females (P = 0.007). Male subjects were more likely to be former or current smokers (P = 0.003). Males with pulmonary TB consumed 35 % excess alcohol per week compared to females (P = 0.001). 20 % of males had COPD compared to 0 % of females (P = 0.002).

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10.3. An Audit of Tuberculosis (TB) Patients Encountered at a Tertiary Referral Centre over a 5 Year Period; Need for Proforma Data Collection? Z. Sharif, S. McConkey, E. De Barra Infectious Disease Department, Beaumont Hospital, Dublin The purpose of this study was to identify aspects of improvement in clinical evaluation, investigation and care of Tuberculosis patients within our service at a tertiary referral centre. A Retrospective chart analysis was carried out using a proforma data collection tool (Table 1). Inclusion criteria; • • •

5 year period between 01/2009 and 01/2014 Treated for diagnosed TB Contact with the infectious disease team either as the primary team or consult.

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Record of follow up at the infectious disease outpatient clinic.

Results: 49 patients met the inclusion criteria • • • •

HIV status was only documented 37/49 case Public Health notified 33/49 cases as per chart documentation Baseline weight only reported in 8/49 cases 19 of 23 Pulmonary cases had sputum documented at 8 weeks. This is a key outcome measure. Cases where the sputum is still culture positive at 8 weeks run a higher risk of treatment failure.

We have identified areas for improvement as highlighted above. We propose the implementation of a proforma to improve data collection at first point contact which will lead to improved quality of care with more adherence to the national TB care guidelines. This will include another audit after rolling out this proforma to evaluate for change in clinical practice. Table 1 Identifiers (Name, Sex, Chart No) Date of first review Date of birth Baseline weight Country of birth Interpreter Language Referral source GP informed Patient information leaflet given Public health informed HIV status Date of HIV test Pregnancy Viral hepatitis Patient type TB site Date of diagnosis Method of diagnosis Drug sensitivity RIF/INH probe Sputum at 8 weeks Baseline tests Baseline opthalmology review Alcohol history Past medical history Treatment plan Treatment outcome Duration Comments

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10.4. Mycobacterium tuberculosis Drives Aerobic Glycolysis and IL-1b in Infected Macrophages which Limits Intracellular Bacillary Survival L.E. Gleeson1, F. Sheedy1, S. O’Leary1, M. O’Sullivan1, L.A.J. O’Neill2, J. Keane1 1

Institute of Molecular Medicine, Trinity Centre for Health Sciences, SJH, Dublin 8, 2Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2 Mycobacterium tuberculosis (Mtb) infection remains a major global health problem and the emergence of MDR- and XDR-strains has compounded the need for novel therapeutic approaches. Recently, research in the field of immunometabolism has linked metabolic changes in macrophages to pro-inflammatory function, with LPSstimulated macrophages adopting glycolysis as their primary method of glucose metabolism in place of oxidative phosphorylation [1]. As alveolar macrophages (AMs) represent the first line of host defence against Mtb, we sought to elucidate the effect of Mtb infection on macrophage glucose metabolism and investigate downstream effects on the host response. Primary human and murine macrophages were infected with avirulent Mtb strain H37Ra or irradiated H37Rv in the presence or absence of glycolytic inhibitors. Macrophage responses and intracellular bacterial growth were measured by quantifying levels of proinflammatory cytokines and by colony counting, respectively, and macrophage metabolic output was monitored by measurement of the glycolytic metabolite D-lactate. Statistical analyses were performed using standard statistical software (Prism 5.0) and significance level was set at p \ 0.05. Mycobacterium tuberculosis (Mtb) infection induced aerobic glycolysis in macrophages. Inhibition of infection-induced glycolysis decreased production of pro-inflammatory IL-1b at both mRNA and protein level. TNFa levels were unchanged. Inhibiting glycolysis also increased bacillary intracellular survival. This effect on bacillary intracellular survival was not seen in the presence of anti-IL-1b antibody, suggesting that the effect is mediated via glycolysis-induced production of IL-1b. Our results demonstrate that Mtb infection alters macrophage glucose metabolism and this is required for optimal production of IL1b. Consistent with previous work implicating IL-1b production as critical for host resistance to Mtb infection [2], we further demonstrate that glycolysis-induced production of IL-1b plays a role in limiting intracellular survival of the bacillus. Our findings suggest that the exciting new field of immunometabolism could aid in developing novel therapeutic approaches to Mtb infection. References: 1. Tannahill GM, Curtis AM, Adamik J et al (2013) Succinate is an inflammatory signal that inducesIL-1b through HIF-1a. Nature, 496(7444):238–243 2. Mayer-Barber KD, Barber DL, Shenderov K et al (2010) Caspase-1 Independent IL-1b production is critical for host resistance to Mycobacterium tuberculosis and does not require TLR signalling in vivo. J Immunol 184(7):3326–3330

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10.5. Pleural Tuberculosis in the Munster region, 2009–2013

10.7. Role of Modified VATS in Stage 3 Empyema: Our Experience

L.J. Chawke, D.B. Fitzgerald, R.P. Cusack, J.S. O’Sullivan, T.M. O’Connor

N. Mayooran, M.N. Anjum, M. Anwer, K. Doddakula Cardiothoracic Surgery, Cork University Hospital, Ireland

Department of Respiratory Medicine, Mercy University Hospital, Cork A retrospective review of patients diagnosed and treated with pleural tuberculosis (TB) from 2009 to 2013 was carried out in the Munster region. Twenty-eight patients were identified from the TB database. For each patient, a review of the hospital laboratory system to assess characteristics of pleural fluid, pleural fluid TB culture, AFB sputum, bronchial washings, pleural biopsy results and adenosine deaminase levels were recorded. Of the 28 patients identified, 17 were male and 11 female. All had symptoms suggestive of TB. The mean age was 51 year and 2 months. All patients had bronchoscopy performed. All patients were smear negative (sputum, pleural fluid). 20 patients had a lymphocytic exudative effusion recorded, which were also negative for malignant cells. Nine of these cultured Mycobacterium tuberculosis on pleural fluid. The remaining 8 (of 28) patients were referred for pleural biopsy, revealing a granulomatous inflammation suspicious for TB. One patient had culture positive bronchial washings, with a negative culture of pleural fluid and sputum. This review highlights the diagnostic challenges associated with pleural TB. In patients with pleural effusions suspicious for TB, the diagnosis of pleural TB is based on patient symptoms microbiology and pathology (granulomas).

10.6. Therapeutic Drug Monitoring of Isoniazid and Rifampicin in Acute TB Treatment M. Higgins, D. Watchorn, C. McDonald, J. Keane, A.M. McLaughlin TB service, Department of Respiratory Medicine, St. James’s Hospital, Dublin 8 The treatment of tuberculosis infection is well established. The dosing of isoniazid and rifampicin are weight based. We present the factors leading to varying drug levels as well as the use and benefit of monitoring anti tuberculous drug levels in our clinical practice. Herein, we present a series of four cases of pulmonary TB from St James’s Hospital Dublin. In three of these cases the patients failed to improve on standard treatment and in one case the patient had relapsed TB infection despite Directly Observed Treatment. However, by using drug monitoring of serum levels of isoniazid and rifampicin and subsequent dose adjustment, therapeutic serum levels of the drugs were obtained and this paralleled a clinical, microbiological and radiographic improvement. These cases demonstrate that low serum levels of isoniazid and rifampicin may be responsible for a delayed recovery in some patients and that dose adjustment according to serum levels has an important role in TB management.

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Traditionally stage 3 empyema is treated by performing posterolateral thoracotomy and ribs spreading with or without rib excision. Thoracotomy is associated with significant morbidity and increased length of stay having economic implications. In our centre, we performed 16 cases of stage 3 empyema by VATS along with 3 cm utility incision with or without excision. No ribs spreading was performed. Average length of stay of patients was 5 days with very good pain control and excellent radiological improvement. Hence we propose that this technique is superior to traditional thoracotomy which is the gold standard for stage 3 empyema.

10.8. Mediastinal Granulomatous Lymphadenitis: Rate of TB Culture Positivity from EBUS and TBNA Samples: a one year Retrospective Study P. Molony*, M Kennedy, T.J. Browne*, J. McCarthy* Department of Pathology, Cork University Hospital, Cork Mediastinal lymph nodes sampled by Endobronchial Ultrasound Fine Needle Aspiration (EBUS) and Transbronchial Needle Aspiration (TBNA) often demonstrate granulomatous inflammation, the main differential of which includes Sarcoidosis and Tuberculosis. As Sarcoidosis remains a ‘‘diagnosis of exclusion’’ pathologically; samples from granulomatous lymph nodes are routinely sent for Mycobacterial culture in our institution; acknowledging that in our catchment area Sarcoidosis is more prevalent than Mycobacterial infection (1, 2). The culture positive rate from such samples was assessed in this study. Cytology laboratory records for 2013 were searched for EBUS and TBNA samples. Cases with malignant cytology were excluded. Microbiologic records were searched for all Mycobacterial cultures in 2013. 128 cases were included and of these 66 (51.5 %) showed granulomatous disease with 62 being cultured. In 18/62 (29 %) cases, BAL was also sent. 1/66 (1.5 %) cultured Mycobacteria (from an immunosuppressed patient), compared to a background rate of 4.45 % for all patient sputum cultures. This study suggests that although culture positive cases are rare, we would advocate this practice to prevent the negative financial and public health implications of a missed TB diagnosis. Submission of BAL in addition has no added value and this practice could be curtailed as a cost saving measure. References: 1. Nicholson TT, Plant BJ, Henry MT, Bredin CP (2010) Sarcoidosis in Ireland: regional differences in prevalence and mortality from 1996 to 2005. Sarcoidosis Vasc Diffuse Lung Dis, 27(2):111–120 2. Kennedy MP, O’Connor TM, Ryan C, Sheehan S, Cryan B, Bredin C (2003) Nontuberculous mycobacteria: incidence in Southwest Ireland from 1987 to 2000. Respir Med 97(3):257–623

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10.9. Prevalence and Pattern of Tuberculosis Cases in a Northern Irish Health and Social Care Trust 2000–2013 Rachael Burke, Fardosa Jama, Nuala MacNiece, Liam Polley, Naomi Chapman, Alexander John, Rory Convery Craigavon Area Hospital, Lurgan Road, Portadown Tuberculosis incidence is increasing in Northern Ireland, albeit from a low baseline. We undertook this study to gain a clearer idea of tuberculosis incidence in Southern Health and Social Care Trust (SHSCT). The SHSCT is the fastest growing of 5 trusts in Northern Ireland and has the greatest rate of international in-migration. Data were supplied from the SHSCT laboratory concerning all culture-confirmed tuberculosis samples 2000–2013. Using the Northern Ireland Electronic Care Record and we were able to linked patient data to the laboratory results. There were 157 cases of TB in this 13 year period. There was a significant increase in cases over this period (p = 0.04). Over the past 13 years an increasing proportion of TB cases have been in patients born outside of Northern Ireland (p = 0.02). The patients from outside Northern Ireland are significantly younger than those born in Northern Ireland (median age 33 vs. 68 respectively, p = 0.00). There were 106 cases of pulmonary TB (68 %) and 51 (32 %) extra pulmonary cases. There were 4 cases of MDR-TB and 4 cases of HIV-associated TB. Consideration should be given to whether there is any role for enhanced case finding for tuberculosis among younger migrants to the SHSCT area.

10.10. Demographics and Outcome of Patients with Tuberculosis in the Munster region, 2009–2013 RP. Cusack1, L.J. Chawke1, S.A. Landers1, D.J. O’Brien2, T.M. O’Connor1 Departments of 1Respiratory Medicine and 2Microbiology, Mercy University Hospital, Cork Although the incidence of tuberculosis (TB) has declined in recent years in Ireland, the number of cases increased from 2001 to 2005 due to immigration. We performed a retrospective review of 276 cases treated for tuberculosis between 2009 and 2013 in a tertiary referral centre. 276 patients (76 % Irish, 24 % foreign born from 28 countries) aged 14–84 years with an average age of 43.75 years were studied. 171 (62 %) were male. 24 cases (9 %) had relapsed. In 169 (61 %) cases,

S539 TB cultures were pan-sensitive, 15 (5 %) cases were resistant and in 89 (32 %) cases, sensitivities were unknown. 2 % of patients were HIV positive and 2 % hepatitis B or C positive. Directly observed therapy was applied in 64 (23 %) cases. Side effects were recorded in 97 (35 %) cases with treatment changed in 35 (13 %) cases. The most common side effects were: nausea (44 cases), abnormal liver function (28 cases), joint pain (17 cases), rash (16 cases). Treatment was completed in 244 (88 %) cases. In 9 cases treatment was ongoing, 7 cases were followed up in other institutions, 12 were under follow up with public health, 3 died, and in 1 case treatment was not completed. TB predominantly affected younger patients. Compliance to therapy was satisfactory. References: 1. Brennan N, McCormack S, O’Connor TM. Ireland needs healthier lungs—the evidence. INHALE Report 2nd Edition 2. Treatment of tuberculosis guidelines 4th Edition, WHO

10.11. Investigation into patient attitudes and barriers to influenza vaccination in a cohort of high-risk patients attending respiratory outpatient clinics F. Jones, S. Foley, P.M. Rogan Department of Respiratory Medicine University Hospital Waterford Influenza vaccination is a key component in the management of many pulmonary diseases. Failure to vaccinate is associated with higher morbidity and mortality. Despite this, uptake is poor among many respiratory patients. There is scant literature relating to specific patient barriers to uptake of influenza vaccination among patients with respiratory illness. In order to investigate this further, an anonymous patient questionnaire was administered to patients attending general respiratory outpatient clinics at our University hospital over a 3 month period. A total of 167 patients completed the questionnaire. Only 59 % of patients had been vaccinated despite 81 % reporting awareness of the benefits. The majority reported a chronic respiratory illness with COPD and asthma predominating. 25 % of patients reported chronic steroid use. A significant proportion of patients failed to identify a number of important indications for influenza vaccination. A number of factors limiting uptake were identified as well as factors that could potentially increase future uptake, including increased access and information. This study highlights poor influenza vaccination rates in a subset of patients at risk of avoidable and potentially serious consequences. It also identifies potential barriers to vaccination and offers insights into potential strategies that could increase future vaccination rates.

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Irish Thoracic Society Poster Review and Discussion Saturday 8th November 2014

11. Cystic Fibrosis and Bronchiectasis Chair

R. Rutherford, Galway University Hospital

11.1. Clinical Impact of Non-Tuberculous Mycobacterial Infection in Cystic Fibrosis A. Natarajan, C. O’Driscoll, K. Schaffer, T. McDonnell, C.G. Gallagher, E.F. McKone St. Vincent’s University Hospital Dublin, Ireland Background: Non-Tuberculous Mycobacteria (NTM) are emerging serious pathogens in cystic fibrosis (CF) patients. Aims: To study the clinical impact of NTM infection in Cystic Fibrosis patients attending St. Vincent’s University Hospital. Methods: We retrospectively reviewed the charts of 48 patients in the National Referral Centre for Adult Cystic Fibrosis in Dublin, who had at least one sputum culture positive for NTM. The clinical parameters were gathered for 2 years before and after acquisition of NTM Infection. Results: The prevalence of NTM in SVUH CF Centre is 15 %, with an age distribution of 22–55 years. NTM is more common in males (n = 25) than females (n = 23). The F508del/F508del is commonest gene mutation identified (50 %). Mycobacterium chelonae was isolated in 66 % (n = 32), followed by Mycobacterium abscesses in 33.3 % (n = 16). The presence of GERD, Low vitamin D, CF related diabetes and ABPA were common in patients with NTM isolation. FEV1 decline in 2 years in patients who cultured NTM once and more than once was 9 and 18 % respectively which is greater than average. The number of exacerbations increased twofold after NTM acquisition as illustrated in figure 1. Conclusion: Rapidly deteriorating lung function and significantly higher number of exacerbations necessitates CF patients to be closely monitored even with one positive NTM culture and treatment initiated earlier to prevent rapid progression of the disease. Figure 1: Exacerbation frequency 2 year before and after NTM isolation. 15

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11.2. Outcomes after 1 Year of Ivacaftor Treatment in CF Patients with at least one G551D-CFTR Mutation: a Single Centre Experience C. Varghese, B. Grogan, P. Farrell, C.G. Gallagher, E.F. Mc Kone St Vincents University Hospital, Dublin Ivacaftor, a CFTR potentiator is the first drug known to treat the underlying cause of cystic fibrosis. Ivacaftor is approved for

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use in cystic fibrosis patients with at least one G551D-CFTR mutation. Objective: To evaluate the clinical responses in CF patients treated with Ivacaftor over a period of 16 months from March 2013 to July 2014. Methods: A retrospective analysis of the clinical outcomes, safety and tolerability of Ivacaftor in CF patients over a period of 16 months was evaluated. We included clinical parameters such as changes in weight, FEV1; sweat chloride, number of exacerbations, and improvement in exercise tolerance from baseline. Results: There is a statistically significant improvement in weight (p = 0.0007) and FEV1 (p = 0.0006) from the pre-ivacaftor baseline. Most of the patients reported improvements in exercise tolerance and quality of life. While 40 % patients noticed a significant reduction in the use of IV antibiotics and hospitalisation rates, 13 % of patients still required IV therapy for exacerbations during the year after commencing ivacaftor. Patients tolerated Ivacaftor very well with no clinically significant adverse effects including deterioration in liver functions. Conclusion: A clinically significant improvement in various clinical parameters is seen in G551D-CFTR CF patients treated with Ivacaftor.

11.3. The Mechanism of Increased Primary Granule Release by Neutrophils of Individuals with Cystic Fibrosis Explored F.S. Gargoum, S.A. Landers, K. Pohl, E.P. Reeves, N.G. McElvaney Respiratory Research Division, Department of Medicine, Royal College of Surgeons of Ireland, Education and Research Centre, Beaumont Hospital, Dublin 9 The purpose of neutrophils is to travel to the site of infection where they kill invading bacteria by phagocytosis and release cytotoxic granules. However, the degranulation process in neutrophils of individuals with cystic fibrosis (CF) is altered, as greater levels of primary granule components are released [1], leading to extensive tissue damage. As circulating neutrophils express CFTR, the aim of this study was to investigate whether impaired primary granule release by CF cells is due to the intrinsic defect. Circulating neutrophils were purified from blood of patients with CF and from healthy control individuals (n = 5). Cells were stimulated with TNF-alpha, LPS and/or fMLP for up to 20 min and the level of degranulation was determined by Western-blot analysis. Statistical comparisons were performed by Student’s t test. Cystic fibrosis (CF) neutrophils released significantly greater levels of serine proteases including proteinase 3, neutrophil elastase (NE) and cathepsin G when compared to healthy control cells (P \ 0.05). Furthermore, degranulation of azurocidine, the potent monocyte activator, and the heme protein myeloperoxidase, by CF neutrophils was significantly higher compared to control cells (P \ 0.05). The molecular basis for this enhanced degranulation involving phospholipase D activation is being explored. Collectively, this study has identified enhanced neutrophil degranulation as a potential parameter of disease progression in CF. We hypothesise that this intrinsic defect may be normalised by CFTR correctors and potentiators thereby reducing inflammation in patients with CF. References: 1. Taggart, C et al (2000) Increased elastase release by CF neutrophils is mediated by tumor necrosis factor-alpha and interleukin-8. Am J Physiol Lung Cell Mol Physiol 278, L33–41 2. Pohl, K et al (2014) A neutrophil intrinsic impairment affecting Rab27a and degranulation in cystic fibrosis is corrected by CFTR potentiator therapy. Blood. doi:10.1182/blood-2014-02-555268.

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11.4. Value of Bronchoalveloar Lavage (BAL) in Management of Lung Infections in Adult Cystic Fibrosis A. Natarajan1, P. Nadarajan1, C. Flanagan2, C. Gallagher1, E. McKone1 1

National Referral Centre for Adult Cystic Fibrosis, St Vincent’s University Hospital, Dublin 2Endoscopy Unit, St Vincent’s University Hospital, Dublin Early diagnosis and treatment of infections is the mainstay of management of lung disease in adult cystic fibrosis, particularly in those with Pseudomonas Aeruginosa. Treatment is guided by sputum culture results in the majority of cases. While bronchoalveolar lavage (BAL) is an alternative diagnostic tool, evidence for its clinical benefit is lacking. Our aim was to determine if bronchoalveolar lavage altered antimicrobial therapy in the management of lung infections in adults with cystic fibrosis. We performed a retrospective audit of BAL done on adult cystic fibrosis patients during acute infective exacerbations. Sputum was obtained during the same exacerbation for culture. Results from BAL and sputum were compared to establish if there were differences in the microbiome profile and if this altered the existing antimicrobial therapy. Thirty-nine patients underwent bronchoscopy for BAL over a period of 6 years (15 F, 24 M). Mean FEV1 was 1.84 L (range 0.42–3.95 L). Treatment was altered in four patients (10.2 %) as a result of BAL culture findings. Pseudomonas Aeruginosa was the most common pathogen cultured from both sputum and BAL (66 % of all samples). BAL did not alter treatment in 90 % of patients during infective exacerbation of cystic fibrosis. As BAL resulted in a change of therapy for only a minority of CF patients, further work is required to identify CF patients that will benefit from BAL.

11.5. From the Sargasso Sea to the West coast of Ireland: The First Reported Cases of Burkholderia Contaminans in Patients with Cystic Fibrosis

pipercillin/tazobactam and ceftazidime; resistant to aztreonam and tobramycin. Both brothers were treated with intravenous meropenem and ceftazidime, oral ciprofloxacin and nebulised tobramycin for 6 weeks. Follow up sputum specimens at 6 weeks and 1 year did not yield B. contaminans in either brother and it has not since been identified again in any of our local CF patient cohort. This is the first published report of B. contaminans identified in CF sputum in Ireland. An aggressive anti-BCC regime with rigid compliance led to complete eradication.

11.6. Outcomes of High Risk Pregnancies in Cystic Fibrosis Population: Case series S.C. Carter, C. Carroll, C.G. Gallagher, E.F. Mc Kone St Vincents University Hospital Dublin Increasing life expectancy and fertility amongst female patients with cystic fibrosis presents the challenge of successfully managing pregnancies in this population. Risk factors for high risk pregnancies include decreased FEV1, low BMI, pancreatic insufficiency and diabetes. There have been twenty-eight mothers under the care of our cystic fibrosis unit with a total of forty-five pregnancies. We report the maternal outcomes of four high risk pregnancies that occurred in women with baseline pre-pregnancy FEV1 \ 40 %. All four pregnancies were unplanned in women who were homozygous for the CFTR genotype F508del. Management involved close liaison between CF physicians, obstetricians, neonatologists, anaesthetists and the intensive care unit. All mothers delivered babies by caesarian section in St. Vincent’s University Hospital with immediate transfer of newborn babies to Holles Street maternity hospital. All four babies were born healthy and remained well at 2 years. Immediate post-pregnancy maternal outcomes were good. However, due to advanced CF lung disease, two mothers died within 2 years of delivery.

11.7. Bronchiectasis Audit for Craigavon Area Hospital 1

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R.F. Power , R. Martin , C. Dunne , N. O’Connell , Casserly , B. Linnane1 CF Unit, University Hospital Limerick 2 Microbiology Department, University Hospital Limerick 3 Director of Research, University of Limerick Burkholderia contaminans belongs to a group of closely related bacteria called the Burkholderia cepacia complex (BCC). BCC species are of increasing significance because of their innate multiresistance to antimicrobial substances and their high transmission rate in susceptible patients. We aim to describe the discovery of B. contaminans in patients with cystic fibrosis (CF) in Ireland. The microbiological and clinical data of two index cases of brothers with CF infected with B. contaminans were reviewed. The first case was detected when B. contaminans was identified in the sputum of a 14 year old boy, at annual review. His brother subsequently yielded the same organism. The isolates were confirmed by the Anti-Microbial Resistance and Healthcare Associated Infections reference unit (AMRHAI) using recA gene sequencing and molecular typing by PFGE showed the isolates to be indistinguishable, with susceptibility to ciprofloxacin, cotrimoxazole, meropenem,

D. Comer, A. John, R. Convery, N. Chapman, L. Polley Respiratory Department, Craigavon Area Hospital, Portadown, BT63 5QQ The 2010 and 2011 British Thoracic Society (BTS) non-cystic fibrosis (CF) bronchiectasis audits highlighted non-adherence to national standards. We audited our performance and aimed to compare patient burden of care with equivalent national values. Data was collected retrospectively for 35 patients to establish if the seven recommendations drawn from the initial BTS bronchiectasis guidelines were met (use of airway clearance, baseline symptoms documented when stable, diagnosis established by HRCT scanning, screening for immunodeficiency, spirometry monitored, testing for CF if age \40, sputum microbiology monitored and rehabilitation offered for MRC grade 3 dyspnoea). Gender, chronic infection with Pseudomonas Aeruginosa (PA), number of exacerbations in the preceding year, requirement for azithromycin, mucoloytic therapy and use of inhaled corticosteroids were determined. All seven recommendations were clearly met. There was a lower percentage of chronic infection with PA (14 %) for our patient group

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S542 in comparison to national data (21 %), reduced number of exacerbations in the preceding year, and fewer admissions for intravenous antibiotics (7 vs. 16 %). Use of azithromycin, nebulised antibiotics, mucolytic therapy and inhaled corticosteroids was lower for CAHGT patients. BTS bronchiectasis guidelines were adhered to with a reduced burden of care among our patient group in comparison to national data.

11.8. The Use of Hypertonic Saline for Airway Clearance in Patients with Bronchiectasis in a District General Hospital C. King, D. Todd, R. Sharkey, M.G. Kelly, M. Mc Closkey Respiratory Medicine Department Altnagelvin Area Hospital Nebulised Hypertonic Saline has been increasing used as an adjunct to airway clearance in patients with Non CF related Bronchiectasis. The aim of this study was to assess patients with Non CF Bronchiectasis attending this District General Hospital who have used Hypertonic Saline. This was retrospective audit looking at all patients who had used Hypertonic Saline (7 % saline) via nebuliser. Compliance, tolerability and outcome as regards antibiotic prescription and sputum positivity in the months before and after twice daily nebulisation with 7 % saline were assessed. Thirty-six patients with Bronchiectasis were given a trial of 7 % hypertonic saline via nebuliser. Six patients stopped it due to poor taste in mouth. No patients stopped due to bronchospasm. Compliance with treatment was poor with 19 patients admitting to taking it once daily only. Five patients admitted they took it erratically. Comparison data of antibiotic usage and sputum positivity could not be assessed reliably due to poor compliance. The six patients who did take it regularly were chronically colonised with Pseudomonas species before starting treatment. Nebulised Hypertonic Saline is inexpensive but doing a test trial to assess suitability takes 90 min and this study shows compliance is poor in this District General Hospital. Time taken for nebulisation is a given explanation (20 min) for something which is perceived as ‘‘Not a Drug’’ but there may be other factors and better identification of those most likely to take the medication may reduce time spent on unnecessary test trials.

11.9. High Prevalence of Urinary Incontinence in Adult Patients with Bronchiectasis N. Duignan, M.J. McDonnell, M.C. Mokoka, R.M. Rutherford Galway University Hospital Introduction: Stress urinary incontinence (SUI) affects 10–30 % of the population. Chronic productive cough, as occurs in bronchiectasis, may predispose to the development of SUI. Such patients are often reticent to discuss their incontinence issues and often go untreated.

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Ir J Med Sci (2014) 183 (Suppl 11):S483–S542 Methods: We conducted a retrospective study of consecutive female bronchiectasis patients attending our physiotherapy service for airway clearance techniques from Jan 2013 to Jun 2014 to determine the prevalence of SUI and the severity of symptoms using the ICIQ-SF (International Consultation on Incontinence-Short Form) symptom and quality of life (QoL) questionnaire. Results: 40 female bronchiectasis patients were identified; 48 % (19 patients, mean age 63 years, range 38–86) had SUI. Mean ICIQ score was 3.7 (range 0–13). 74 % reported SUI as interfering with their everyday QoL. Patients were educated regarding pelvic floor exercises and the ‘knack’ technique. A follow-up phone call was made to assess need for referral to women’s health specialist physiotherapy. 69 % felt their symptoms had significantly improved on follow-up with specialist referral requested by only 5 patients. Conclusion: SUI is common in bronchiectasis. It is rarely selfreported and negatively affects QoL. It is important to screen for SUI and provide education and specialist referral where necessary to improve continence and QoL.

11.10. Translational research for chronic respiratory disease: intercepting the bile aspiration paradigm F.J. Reen1, D. Woods1, S. Flynn1, M. Nı´ Chro´inı´n2, D. Mullane2, S.M. Stick3, C. Adams1, F. O’Gara1,4 1

BIOMERIT Research Centre, School of Microbiology, University College Cork, Ireland. 2Paediatric Cystic Fibrosis Clinic, Cork University Hospital, Cork, Ireland. 3Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, WA, 6008, Australia. 4School of Biomedical Sciences, Curtin University, Perth, WA, 6845, Australia. Chronic respiratory disease is a major cause of global morbidity and mortality and is characterised by persistent lung infections, chronic inflammation, and a gradual decline in lung function. Current treatment strategies remain extremely limited, being particularly hampered where pathogens adopt the biofilm antibiotic resistant lifestyle. There is growing evidence that aspiration of bile acids into the lungs may be linked to increased morbidity and mortality in chronic respiratory disease. We have recently demonstrated that we can detect bile acids in sputum and broncheolar lavage of some Cystic Fibrosis patients and have shown that the presence of specific bile acids correlates with a significant [Mann-Whitney U-test p\0.05)] reduction in lung microbial biodiversity and the emergence of dominant Proteobacterial pathogens. Increased production of inflammatatory biomarkers has also been observed in aspirating patients These observations are consistent with our in vitro studies which have shown that bile, and in particular bile acids, trigger the establishment of dominant chronic biofilm forming microbial species, particularly Pseudomonas aeruginosa, while dysregulating the hypoxic and immune responses in airway epithelial cells. Understanding the bile aspiration paradigm will provide a real opportunity to develop innovative therapies that prevent establishment of chronic respiratory infections, rendering pathogens susceptible to conventional antibiotics

Irish thoracic society annual scientific meeting 2014.

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