Background: Patients with chronic obstructive pulmonary disease (COPD) pose a significant burden to healthcare providers with frequent exacerbations necessitating hospital admission. Randomised controlled data exist supporting the use of acute non-invasive ventilation (NIV) in patients with exacerbations of COPD with mild to moderate acidosis. The use of NIV is also described in chronic stable COPD, with evidence suggesting a reduction in hospital admissions and general practitioner care. We present economic data on the impact of domiciliary NIV on the need for admission to hospital and its attendant costs. Methods: A cost and consequences analysis of domiciliary NIV based on a before and after case note audit was performed in patients with recurrent acidotic exacerbations of COPD who tolerated and responded well to NIV. The primary outcome measure was the total cost incurred per patient per year from the perspective of the acute hospital. Effectiveness outcomes were total days in hospital and in intensive care. Results: Thirteen patients were identified. Provision of a home NIV service resulted in a mean (95% CI) saving of £8254 (£4013 to £12 495) (J11 720; J5698 to J17 743) per patient per year. Total days in hospital fell from a mean (SD) of 78 (51) to 25 (25) (p = 0.004), number of admissions from 5 (3) to 2 (2) (p = 0.007), and ICU days fell from a total of 25 to 4 (p = 0.24). Outpatient visits fell from a mean of 5 (3) to 4 (2) (p = 0.14).Conclusions: This study suggests that domiciliary NIV for a highly selected group of COPD patients with recurrent admissions requiring NIV is effective at reducing admissions and minimises costs from the perspective of the acute hospital. Such evidence is important in obtaining financial support for providing such a service.

Background: Non-invasive ventilation is an established treatment for chronic respiratory failure due to chest wall deformity. There are few data available to inform the choice between volume and pressure ventilators. The aim of this study was to compare pressure and volume targeted ventilation in terms of diurnal arterial blood gas tensions, lung volumes, hypercapnic ventilatory responses, sleep quality, and effect on daytime function and health status when ventilators were carefully set to provide the same minute ventilation. Methods: Thirteen patients with chest wall deformity underwent a 4 week single blind randomised crossover study using the Breas PV403 ventilator in either pressure or volume mode with assessments made at the end of each 4 week period. Results: Minute ventilation at night was less than that set during the day with greater leakage for both modes of ventilation. There was more leakage with pressure than volume ventilation (13.8 (1.9) v 5.9 (1.0) l/min, p = 0.01). There were no significant differences in sleep quality, daytime arterial blood gas tensions, lung mechanics, ventilatory drive, health status or daytime functioning. Conclusions: These data suggest that pressure and volume ventilation are equivalent in terms of the effect on nocturnal and daytime physiology, and resulting daytime function and health status.

In normal subjects, heated humidification during nasal NIV attenuates the adverse effects of mouth leak on effective tidal volume, nasal resistance and improves overall comfort. Heated humidification should be considered as part of an approach to patients who are troubled with nasal symptoms, once leak has been minimised.

Churg-Strauss syndrome is a rare form of eosinophilic vasculitis associated with asthma. There have been several recent case reports of the condition in association with leukotriene antagonists and it has been speculated that the ChurgStrauss syndrome was unmasked when oral corticosteroids were withdrawn. We report a case of Churg-Strauss syndrome associated with montelukast therapy in an asthmatic patient in whom there had been no recent oral corticosteroid use. We believe that this is the first such reported case and would suggest that clinicians need to be vigilant in all patients who develop systemic symptoms when starting treatment with leukotriene antagonists. (Thorax 2000;55:805-806)

Purpose -The purpose of this paper is to observe and analyse the effects of the use of telemedicine in care homes on the use of acute hospital resources. Design/methodology/approach -The study was an uncontrolled retrospective observational review of data on emergency hospital admissions and Emergency Department (ED) visits for care home residents in Airedale, Wharfedale and Craven. Acute hospital activity for residents was observed before and after the installation of telemedicine in 27 care homes. Data from a further 21 care homes that did not use telemedicine were used as a control group, using the median date of telemedicine installation for the "before and after" period. Patient outcomes were not considered. Findings -Care homes with telemedicine showed a 39 per cent reduction in the costs of emergency admissions and a 45 per cent reduction in ED attendances after telemedicine installation. In the control group reductions were 31 and 31 per cent, respectively. The incremental difference in costs between the two groups of care homes was almost £1.2 million. The cost of telemedicine to care commissioners was £177,000, giving a return on investment over a 20-month period of £6.74 per £1 spent.Research limitations/implications -The results should be interpreted carefully. There is inherent bias as telemedicine was deployed in care homes with the highest use of acute hospital resources and there were some methodological limitations due to poor data. Nevertheless, controlling the data as much as possible and adopting a cautious approach to interpretation, it can be concluded that the use of telemedicine in these care homes was cost-effective. Originality/value -There are very few telemedicine studies focused on care homes.

Background: The British Thoracic Society (BTS) recommendations for patients with respiratory disease planning air travel suggest that an oxygen saturation (SaO 2 ) .95% precludes the need for any further assessment of the need for supplemental oxygen during flight. A hypoxic challenge test (HCT) is recommended for patients with a resting SaO 2 between 92% and 95% with an additional risk factor, including kyphoscoliosis (KS) or neuromuscular disease (NMD). However, this recommendation was based on very few data. Patients and methods: HCTs were performed on 19 adult patients with KS and/or NMD (age 22-73 years, forced expiratory volume in 1 s (FEV 1 ) 0.76, forced vital capacity (FVC) 0.92, SaO 2 95%, partial pressure of arterial CO 2 (PaCO 2 ) 5.7 kPa) who were at risk for nocturnal hypoventilation. 15 were home ventilator users. Arterial blood gas measurements were made before and at the end of the hypoxic challenge. Results:The results of HCTs show that the majority (15 of 19) of this cohort of patients met the criteria suggested by the BTS Standards of Care Committee for in-flight oxygen regardless of baseline SaO 2 . Conclusions: This finding suggests that all patients with severe extrapulmonary restrictive lung disease should undergo assessment with HCT prior to air travel. The study confirms that even patients with a resting saturation of .95% can desaturate significantly during hypoxic challenge. This study does not address the question of whether desaturation at altitude has any adverse consequences for patients. A decision as to whether it is safe for a patient to fly should be made by an experienced clinician and based on a number of factors, which should include previous travel experience, the patient's overall condition and the results of an HCT.In 2002 the British Thoracic Society (BTS) Standards of Care Committee published recommendations for managing patients with respiratory disease planning air travel.1 It was recommended that assessment should include pulse oximetry, with arterial blood gas analysis being preferred if hypercapnia is suspected. Supplemental oxygen during flight is not recommended for patients with a resting oxygen saturation (SaO 2 ) at sea level of . 95% or for those with a saturation between 92% and 95%, without an additional risk factor. For those with an SaO 2 between 92% and 95% at sea level and an additional risk factor, a hypoxic challenge test (HCT) is recommended. If the SaO 2 is ,92%, supplemental oxygen should be advised for use throughout flight. Preflight assessment is recommended for a variety of specific groups of patients, including those with severe restrictive disease (including chest wall and respiratory muscle disease) with hypoxaemia and/or hypercapnia; these patients should therefore have an HCT if their resting saturation is (95%. If during the hypoxic challenge the partial pressure of arterial O 2 (PaO 2 ) falls below 6.6 kPa, supplemental oxygen is recommended during flight; if it remains above 7.4 kPa, supplemental oxygen is not needed, with val...

Non-invasive ventilation (NIV) is widely used for acute and chronic respiratory failure. If arterial blood gas tensions do not improve, the level of support can be increased. However, there may be a limit above which increasing ventilatory support leads only to greater interface leak with no improvement in ventilation. The aim of this study was to establish whether there is such a limit. During a daytime study in 24 ventilated stable patients (10 with chronic obstructive pulmonary disease (COPD), 14 with chest wall deformity, CWD), inspiratory pressures up to 20 cm H(2)O and set tidal volumes up to 10 ml kg(-1) were associated with mask leak of <5 l min(-1). Although leak increased with higher levels of support, there was still an increase in minute ventilation. The mean (2 sd) tolerated pressure was 24 cm H(2)O (8-40) in both groups, and set tidal volume 12.7 ml kg(-1) (5.0-20.4) in CWD and 9.6 ml kg(-1) (3.9-14.8) in COPD. Measures of respiratory effort were significantly reduced at all levels with both forms of ventilatory support. There is debate about whether the therapeutic aim of NIV should be to reduce respiratory muscle effort, or to reverse nocturnal hypoventilation. We conclude that if the primary aim is to improve arterial blood gas tensions and this is not achieved, higher levels of ventilation can be obtained using greater pressure or volume, despite additional interface leak. If the aim is to abolish muscle effort completely, there is little to be gained by increasing the level of inspiratory pressure above 20 (CWD) or 25 (COPD) cm H(2)O.

Primary pulmonary botryomycosis is a rare cause of haemoptysis and can enter the diVerential diagnosis of a mass on the plain chest radiograph. The case history is presented of a 63 year old man with botryomycosis which was initially thought to be a bronchial carcinoma. When the diagnosis was made several years later it was found to be secondary to persisting vegetable material in the bronchial tree following previous aspiration.