IntroductionPatients with chronic obstructive pulmonary disease often experience exacerbations. These events are important as they are a major cause of morbidity and mortality. Recently, it has been increasingly recognized that patients may experience symptoms suggestive of an exacerbation but do not seek treatment, which are referred to as unreported or untreated exacerbations. Symptom diaries used in clinical trials have the benefit of identifying both treated and untreated exacerbation events.MethodsThe Kamada study was a multicenter, double-blind randomized controlled trial of inhaled augmentation therapy in alpha-1 antitrypsin deficiency (AATD). A retrospective review of daily electronic symptom diary cards was undertaken from the two leading centers to identify symptomatic episodes consistent with a definition of an exacerbation. The aims were to explore the relationship between exacerbation events and classical “Anthonisen” symptoms and to characterize treated and untreated episodes.ResultsForty-six AATD patients with airflow obstruction and history of exacerbations were included in the analysis. Two hundred thirty-three exacerbation episodes were identified: 103 untreated and 130 treated. Untreated episodes were significantly shorter (median 6 days; interquartile range [IQR] 3–10 days) than the treated episodes (median 10 days; IQR 5–18.25 days: P<0.001). Using logistic regression analysis, Anthonisen type and length of dyspnea were significant predictors of the treatment of an exacerbation event.ConclusionReal-time electronic diary cards provide valuable information about the characterization of exacerbations. Untreated episodes are common and are significantly shorter in duration than the treated episodes. Dyspnea is the most important single Anthonisen symptom in the prediction and/or driver of treatment.

: Ambulatory oxygen therapy is indicated in patients that use long term oxygen therapy (LTOT) and current guidelines suggest its use in patients who exhibit exertional desaturation if there is a demonstrable improvement in exercise capacity. Evidence for this is largely derived from single assessment studies which have shown clear benefit in this setting when oxygen versus air is used. The long term effects, however, of ambulatory oxygen therapy in this particular group of patients is controversial. We conducted a systematic review of published literature from 1980 to June 2014 for trials in which ambulatory oxygen was compared to placebo in chronic obstructive pulmonary disease (COPD) patients not on LTOT. We also reviewed the effectiveness of devices delivering ambulatory oxygen. Outcome measures were focused towards exercise capacity, Borg scores and the ability of the delivery devices to maintain oxygen saturations on exercise. Twenty three studies (620 patients) were included in the review. Nine studies evaluated the clinical effectiveness of ambulatory oxygen and 14 studies evaluated the impact of the delivery devices Ambulatory oxygen had no statistical effect on improving exercise capacity when assessed by the 6-minute walk test (6MWT) or the endurance shuttle walk test (ESWT);=0.44 and =0.29 respectively. End of test Borg scores showed no statistical improvement with ambulatory oxygen therapy during 6MWT (=0.68). Oxygen conserving devices significantly improved oxygen saturations on exercise compared with continuous flow nasal cannulae (=0.04). Ambulatory oxygen therapy has limited long term benefit in improving functional exercise capacity or Borg dyspnea scores.

Introduction NIV for acute hypercapnic respiratory failure (AHRF) in COPD, obesity related morbidity, chest wall and neuromuscular conditions has become widespread in the UK over the past decade. In terms of acute NIV set up, the BTS/Royal College of Physicians/Intensive Care Society 2008 guidance recommends starting with an inspiratory positive airway pressure (IPAP) of 10 cm H2O and expiratory positive airway pressure(EPAP) of 4–5 cmH2O, with small increments in IPAP aiming for apressure target of 20 cm H2O or until therapeutic response is achieved. We felt it necessary to analyse trends in maximum pressures achieved in the evolution of a respiratory ward-based NIV Unit (established2004). Methods Comparison of the in-house NIV registry data01/08/2004 –31/01/2006(Period 1) with 01/01/2011–30/06/2012 (Period 2) at an 11-bedded ward-based NIV unit within a1000-bedded hospital Trust in central England, looking at maximum IPAP and maximum EPAP achieved. There were 281 episodes of AHRF treated in Period 1 and 240 in Period 2 with similar distribution of gender. Results Maximum IPAP achieved for period 2 was significantly higher than period 1 (median IPAP max achieved=20 cmH2O vs. 14 cmH2O; Wilcox on rank sum test p=2.2 × 10–16) and the maximum EPAP achieved for period 2 was higher than period 1 (median EPAP max achieved=5 cmH2O vs. 14 cmH2O; Wilcoxonrank sum test p=8.068 × 10–6). Discussion We have previously shown that we achieved adequate therapeutic response with median IPAP max of 16.7 and median EPAP max of 5.2 cmH2O (Ali A et al. Pressure support in acute hypercapnic respiratory failure in an acute clinical setting. European Respiratory Journal 2011; 38:55. 683s.). However, as the ward-based, physiotherapy-intensive, multidisciplinary NIV service matures over an 8-year period, we are achieving significantly higher maximum IPAP and maximum EPAP. This is probably (a) in keeping with the increasing severity of AHRF that is being treated in the unit with similar in-hospital mortality (around 22%) and (b) demonstrates a learning curve. Further analysis of population characteristics and comparison with units of similar size may give further insights intoorganisational learning in relation to NIV. Abstract P220 Figure 1 Comparison of the distribution of the maximum IPAP achievedComparison of the distribution of the maximum EPAP achieved

Background Little is known about the sensations and triggers that provoke cough in patients, or their preferred language to describe their experiences. We have previously collected a list of descriptors covering the themes of triggers, sensations and secretions, generated from individual interviews in a range of respiratory disorders, with a view to developing a questionnaire. Aims To take the key descriptors and present these to focus groups diagnosed with chronic cough, COPD, ILD, asthma, and non-CF bronchiectasis. Methods Five semi-structured focus groups were conducted with 22 participants (7 chronic cough, mean age 67.7 years (range 57-80) 4 female; 5 asthma, age 66 years (60-71) 2 female; 4 COPD, age 68 years (66-73) 2 female; 3 ILD, age 70 years (65-74) 0 female; 3 non-CF bronchiectasis, age 67.3 years (53-77) 2 female). Using simple manifest content analysis, a list of descriptors was derived based on the frequency of use during individual interviews. These were presented to the focus groups, asking them to describe what each word meant to them, the image it conjured up and whether they could identify a most appropriate word. Results All focus groups favoured the terms 'phlegm' over 'sputum' (which was considered too "clinical"), 'irritation' over the word 'tickle' (which was considered too "gentle") and the 'need to cough' over an 'urge to cough'. In contrast, there were distinct differences in some disease groups for example, all groups, apart from COPD, recognised specific foods and eating as triggers of coughing. Similarly, all groups, apart from asthma, identified specific smells and odours as triggers of coughing. Patients with COPD, ILD and non-CF bronchiectasis related to the word 'crackle', but asthmatics only associated this word with "infection" and chronic cough patients did not identify with this terminology. Conclusion These focus group discussions would suggest that whilst some descriptors of cough are felt to be universally appropriate, other descriptors and triggers appear to discriminate between diagnoses. This study will inform the language and content of a future questionnaire to categorise patients by the sensations and triggers provoking their cough.

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