BMJ Open Respiratory Research

Lung health, the development of lung disease, and how well a person with lung disease is able to live, all depend on a wide range of societal factors. Considering COPD as a manifestation of structural violence, something that continues to be done to people, despite it being largely preventable, makes the causal processes more apparent and the responsibility to interrupt or alleviate these clearer. We developed a taxonomy to describe this, containing five domains. 1)Avoidable lung harms: (i)processes impacting on lung development (ii)processes which disadvantage lung health in particular groups across the life course. 2)Diagnostic Delay: (i)healthcare factors (ii)norms and attitudes that mean that COPD is not diagnosed in a timely way, denying people with COPD effective treatment. 3)Inadequate COPD Care: ways in which the provision of care for people with COPD falls short of what is needed to ensure that they are able to enjoy the best possible health, considered as (i)healthcare resource allocation (ii)norms and attitudes influencing clinical practice. 4)Low status of COPD: ways in which both COPD as a condition and people with COPD are held in less regard and considered less of a priority than other comparable health problems. 5)Lack of Support: factors that make living with COPD more difficult than it should be (i)socioenvironmental factors (ii)factors that promote social isolation. This model has relevance for policymakers, healthcare professionals and the public as an educational resource, to change clinical practices and priorities and to stimulate advocacy and activism with the goal of the elimination of COPD.

BackgroundFatigue, breathlessness and cough are prevalent symptoms of Interstitial Lung Disease (ILD) adversely impacting quality-of-life and contributing to psychological distress. The Fatigue and Breathlessness (FAB) programme facilitates supported self-management for people living with life-limiting conditions such as cancer. We explore its utility when adapted for people living with ILD. MethodsThe 4-week ILD-FAB programme offers each group of up to 6 participants weekly two-hour sessions led by an ILD-specialist Physiotherapist and Clinical Nurse Specialist (CNS). Primary focus is on strategies to manage breathlessness, fatigue and wellbeing. Further, a 1:1 session with the ILD-CNS enables participants to set personalised goals and explore individual health beliefs/behaviours using a Cognitive Behavioural Therapy (CBT) assessment framework. The self-reporting Chronic Respiratory Questionnaire (CRQ-SR) evaluates breathlessness, fatigue, emotional function and mastery at baseline and after 4 weeks. We facilitated eleven groups between March 2023 and December 2024. ResultsForty-nine participants (26 male; median age 76 years [IQR=14]) were diagnosed with Idiopathic Pulmonary Fibrosis/IPF (n=21), Progressive Pulmonary Fibrosis/PPF (n=17) or non-progressive ILD (n=11) of various aetiologies. Lung function indicated a range of disease severity (FVC % predicted median: 70% [IQR=34]) Thirty-seven (76%) participants attended all four sessions, 6 (12%) attended three sessions, 2 (4%) attended two sessions and 4 (8%) attended one session. Thirty-seven patients, all who attended at least 3 sessions, completed the CRQ-SR at baseline and Week 4. Fifty-nine percent of respondents (n=22) demonstrated clinically significant improvements in dyspnoea scores, 51% (n=19) in emotional functioning scores and 49% (n=18) in fatigue and mastery scores. Thirty-five respondents (95%) demonstrated a clinically significant improvement in at least one domain. All participants (100%) would recommend this programme to others. ConclusionThese data demonstrate feasibility, acceptability and clinical effectiveness of an ILD-specific FAB programme. Further research will explore a range of outcome measures longitudinally in a larger cohort. Key MessagesO_LIWhat is already known on this topic -The FAB programme is delivered in hospices and NHS trusts UK-wide to improve confidence in fatigue and breathlessness management and reduce anxiety for people living with life-limiting illnesses such as cancer. Formal evaluations are positive but limited by small sample sizes and the use of non-validated outcome measures. C_LIO_LIWhat this study adds -Our FAB programme, adapted for people with ILD, is feasible, acceptable and clinically effective. C_LIO_LIHow this study might affect research, practice or policy - The FAB programme offers one multimodal approach to improving self-management in people with ILD. Further research in a larger, more heterogeneous patient population will optimise outcome measures, broaden acceptability and determine cost-effectiveness. C_LI

IntroductionIntegrating smoking cessation support into lung cancer screening can improve abstinence rates. However, healthcare decision makers need evidence of cost effectiveness to understand the cost/benefit of adopting this approach. MethodsTo evaluate the cost-effectiveness of different smoking cessation interventions, and service delivery, we used a Markov model, adapted from previous National Institute for Health and Care Excellence guidelines on smoking cessation. This uses long-term epidemiological data to capture the prevalence of the smoking-related illnesses, where prevalence is estimated based on age, sex, and smoking status. Probabilistic sensitivity analysis was conducted to capture joint parameter uncertainty. ResultsAll smoking cessation interventions appeared cost-effective at a threshold of {pound}20,000 per quality-adjusted life year, compared to no intervention or behavioural support alone. Offering immediate smoking cessation as part of lung cancer screening appointments, compared with usual care (onward referral to stop smoking services) was also estimated to be cost-effective with a net monetary benefit of {pound}2,198 per person, and a saving of between {pound}34 and {pound}79 per person in reduced workplace absenteeism among working age attendees. Estimated healthcare cost savings were more than four times greater in the most deprived quintile compared to the least deprived, alongside a fivefold increase in QALYs accrued. ConclusionsSmoking cessation interventions within lung cancer screening are cost-effective and should be integrated so that treatment is initiated during screening visits. This is likely to reduce overall costs to the health service, and wider integrated care systems, improve quality and length of life, and may lessen health inequalities. Key messagesO_ST_ABSWhat is already known on this topic?C_ST_ABSSmoking cessation interventions are known to be cost-effective in general. However, their cost-effectiveness specifically within lung cancer screening programmes, where they are not routinely commissioned, remains to be established. What this study addsThis health economic analysis estimates that offering smoking cessation immediately within a lung cancer screening visits is a cost-effective intervention, with a substantial return on investment for the healthcare service, alongside a reduction in health inequalities and an increase in productivity for the wider economy. How this study might affect research, practice or policyThis economic evaluation will provide those commissioning and planning healthcare services with evidence that supports the case for funding smoking cessation services integrated within lung cancer screening programmes as immediate, opt-out services.

IntroductionChronic Obstructive Pulmonary Disease (COPD) is a heterogeneous condition with varied clinical and pathophysiologic characteristics. Although there is increasing evidence that COPD in low- and middle-income countries may have different clinical characteristics from that in high income countries, little is known about COPD phenotypes in these settings. We describe the clinical characteristics and risk factor profile of a COPD population in Uganda. MethodsWe cross sectionally analyzed the baseline clinical characteristics of 323 COPD patients aged 30 years and above who were attending two national referral outpatient facilities in Kampala, Uganda between July 2019 and March 2021. Logistic regression was used to determine factors associated with spirometric disease severity. ResultsThe median age was 62 years; 51.1% females; 93.5% scored CAT >10; 63.8% mMRC >2; 71.8% had wheezing; 16.7% HIV positive; 20.4% had a history of pulmonary tuberculosis; 50% with blood eosinophilic count >3%, 51.7% had 3 or more exacerbations in the past year. Greater severity by GOLD stage was inversely related to age, (aOR=0.95, 95%CI=0.92, 0.97), and obesity compared to underweight (aOR=0.25, 95%CI=0.07, 0.82). Regarding clinical factors, more severe airflow obstruction was associated with SPO2<93% (aOR=3.79, 95%CI=2.05, 7.00), mMMRC[&ge;]2 (aOR=2.21, 95%CI=1.08, 4.53), and a history of severe exacerbations (aOR=2.64, 95%CI=1.32, 5.26). ConclusionCOPD patients in this population had specific characteristics and risk factor profiles including HIV and TB meriting tailored preventative approaches. Further studies are needed to better understand the pathophysiological mechanisms at play and the therapeutic implications of these findings. Key messagesO_LIWhat is already known on this topic. COPD is a heterogeneous condition with the greatest burden in LMICs yet there is limited understanding of disease characteristics in this setting. C_LIO_LIWhat this study adds A cohort of patients with COPD recruited in hospital clinics in Uganda showed a high burden of disease with frequent exacerbations - 86% were GOLD category D. The cohort had a high exposure to biomass smoke and only 38% were past or present smokers. C_LIO_LIHow this study might affect research, practice, or policy There is need for more research into effective strategies to prevent and treat COPD in LMICs - it cannot be assumed that guidelines derived in high-income countries will apply. C_LI

Earlier detection of lung cancer is possible, but difficult and costly to achieve. Screening with Low Dose Computed Tomography (LDCT)scanning has been shown to reduce mortality by 20-25% over the past decade but uptake amongst those most likely to suffer the disease has been slow. Resource constraints and a high false positive rate have also limited adoption of LDCT in many health systems. Targeted screening of people most likely to benefit using a range of biomarkers may be one way to improve the yield and reduce the resource requirements of LDCT. Autoantibodies, which amplify the signal produced by cancer derived proteins, are present in the blood of people mounting an immune response to cancer are a potential way to select those at highest risk. We have followed up 12 208 people enrolled in the ECLS trial for three years and shown that the specificity for early stage (I &II) disease is 90.3% throughout that period. More cancers were detected in the control than the intervention arm of the trial (101V 83). Sensitivity was 77.8% after 6 months and dropped to 46.4% after 3 years. At the end of three years the hazard ratios (95%CI) for All Cause, Cancer Specific and Lung Cancer Mortality was 0.82(0.67-1.01), 0.72(0.54-0.97) and 0.70(0.46-1.08) respectively for those randomised to Early CDT testing. As a range of treatment modalities become increasingly more effective it is even more important to target LDCT on those most likely to have early stage disease. Autoantibody testing may be one method of targeting early detection on those most likely to benefit.

IntroductionUse of home non-invasive ventilation (NIV) to treat persistent hypercapnic respiratory failure in patients with stable chronic obstructive pulmonary disease (COPD) effectively reduces readmission rates and mortality compared with standard therapy. Traditional workflows around the initiation and management of NIV include elective admission for therapy initiation and frequent face-to-face clinic visits for follow-up, but use of telemedicine offers an alternative approach. AimThis retrospective cohort study evaluated the clinical efficacy and health resource use impact of a remote monitoring approach to the initiation and monitoring of home NIV. MethodsIndividuals with COPD, COPD-obstructive sleep apnoea or obesity-related respiratory failure who were started on remote-monitored home NIV from July 2016 to December 2020 were included. Data were obtained from electronic health records. The primary outcome was healthcare utilisation (hospital admissions and average number of bed days) in the 12 months after versus 12 months before starting NIV; secondary endpoints included 2-year survival and time to readmission, and blood gas analysis. ResultsIn the 12 months after versus before NIV initiation, there was a significant reduction in the mean number of admissions (1.0{+/-}2.1 vs. 1.4{+/-}2.1; p<0.0001) and occupied bed days (9.6{+/-}26.8 vs. 17.2{+/-}27.5; p<0.0001); results were consistent across NIV indications. Time to first readmission (hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.58-2.8; p<0.001) and time to death (HR 2.25, 95% CI 1.51-3.34; p<0.0001) were significantly worse in NIV non-users versus users, but did not differ by deprivation quintile. Blood gas analysis showed that NIV significantly reduced carbon dioxide pressure and bicarbonate compared with before NIV. ConclusionsA technology-assisted service model for the remote initiation and monitoring of home NIV therapy for individuals with chronic hypercapnic respiratory failure was feasible, had a beneficial effect on healthcare utilisation and outcomes, and offset typical adverse relative survival outcomes associated with deprivation. KEY MESSAGESO_ST_ABSWhat is already known on this topicC_ST_ABSWhen given at adequate pressures that ensure sufficient reduction in carbon dioxide pressure, home non-invasive ventilation (NIV) is an effective and well tolerated treatment for chronic hypercapnic respiratory failure in individuals with chronic obstructive pulmonary disease or obesity-related respiratory failure. What this study addsThis study showed the feasibility and effectiveness of a remote monitoring approach to the initiation and management of home NIV therapy in a real-world setting. How this study might affect research, practice or policyAs well as improving outcomes in appropriately selected individuals, the initiation and management of home NIV therapy using remote monitoring has the potential to improve workflow, equitably enhance access to and outcomes from treatment, and provide a rich continuous dataset that could facilitate derivation of actionable artificial intelligence insights to support proactive care interventions.

BackgroundInterstitial lung diseases (ILD) are a heterogenous group of often progressive, unpredictable diseases. They frequently result in hospitalisations secondary to respiratory decompensation, termed ILD-related admissions. A proportion of these are due to acute exacerbations (AEILD). All are associated with high mortality but poorly characterised in real-world populations. AimTo evaluate mortality outcomes and associated risk factors following ILD-related hospital admissions, including AEILD. MethodsWe conducted a multicentre retrospective cohort study of primary ICD10 coded admissions for ILD between 01.01.2017 and 31.12.2019 across 11 NHS hospitals in the North West of England. AEILD events were classified using clinical criteria: a <30-day respiratory deterioration not secondary to cardiac failure, pulmonary embolism or pneumothorax. The AEILD sub-group was subsequently divided into those with CT confirmation (definite AEILD) and without CT confirmation (suspected AEILD). Primary outcome was time from admission to death. Statistical analyses included Kaplan-Meier survival and multivariate cox proportional hazards modelling. ResultsOf 938 admissions ILD-related admissions, 54.5% met study AEILD criteria. Overall, 90-day all-cause mortality was 40.2%. Median survival of the AEILD cohort was 107 days (95% CI 87.0 - 141.0 days) and other ILD-related admission cohort 241.0 days (95% CI 208.0 - 308.0 days), with a statistically significant difference in survival (p <0.0001). 37.6% (192/511) of AEILD events had CT confirmation. Within the AEILD sub-group, median survival was higher in the CT group (144 days vs. 100 days, p = 0.027). AEILD was independently associated with mortality in a multivariate model, and pre-admission oxygen, age and neutrophilia were associated with mortality in both ILD-admission and AEILD 90-day all-cause mortality models. Only 13.9% of admissions had documented palliative care input. ConclusionMortality associated with ILD-related admissions is high, with AEILD events independently associated with high mortality. Findings highlight the need for improved education, improved access to palliative care and targeted AEILD research. Key MessagesO_ST_ABSWhat is already known on this topic.C_ST_ABSHospital admissions in interstitial lung disease (ILD) carry a high risk of mortality, particularly when precipitated by an acute exacerbation (AEILD). Prior international surveys have highlighted clinician heterogeneity in the approach to AEILD, but there is very limited real-world data describing admission outcomes, diagnostic and treatment patterns from the UK. What this study adds.This study adds to the understanding that AEILD conveys poor survival outcomes and highlights age, pre-admission oxygen use and neutrophilia as poor prognostic indicators. It highlights underuse of CT for diagnostic confirmation and demonstrates that a lack of CT confirmation is associated with shorter survival in simple modelling. It also demonstrates low palliative care inpatient service utilisation. How this study might affect research, practice or policy.These findings highlight the urgent need for consistent diagnostic pathways, equitable access to CT imaging and early multidisciplinary input for AEILD. Improved education of the non-specialist, patients and their relatives could improve recognition and outcomes in this high-risk population - including timeline access to palliative care and acute admission burden.

BackgroundPrior pulmonary tuberculosis (PTB) is associated with chronic lung impairment, including chronic obstructive pulmonary disease (COPD). We determined the prevalence and associations of chronic respiratory symptoms and COPD following completion of PTB treatment in Uganda. MethodsBetween August 2022 and December 2022, we consecutively enrolled post-PTB patients who had successfully completed PTB treatment between January 2016 and January 2020 at Mulago National Referral Hospital, Kampala, Uganda. Chronic respiratory symptoms were defined as the presence of at least one of the following symptoms lasting for at least three months within a year: cough or sputum production, shortness of breath, chest pain, or wheezing, along with an FEV1/FVC < 0.70 on spirometry for the definition of COPD. ResultsWe enrolled 326 participants (median age 36 years; IQR: 30 -- 43), 182 (55.8%) were male, and 123 (37.7%) were living with HIV. Fifty-one (15.6%) participants had chronic respiratory symptoms, 5 (9.8%) having COPD; 4 GOLD I and 1 GOLD II. Chronic respiratory symptoms were 89% lower among participants whose PTB treatment outcome was "completed" (adjusted Odds Ratio (aOR): 0.11, 95% confidence interval (CI): 0.01 - 0.87, p<0.01) and they were 74% lower among those with alcohol use disorders (aOR: 0.26, 95% CI: 0.12 - 0.57, p <0.001). Non-HIV immunosuppressive conditions such as diabetes mellitus and chronic steroid use, were significantly associated with both chronic respiratory symptoms (aOR:7.72, 95% CI 3.13 - 19.04, p<0.001) and COPD (aOR: 8.42, 95% CI: 1.32 -- 53.47, p=0.024). ConclusionChronic pulmonary symptoms, including COPD, are important and yet under recognized complications of PTB treatment in Uganda. Therefore, screening and management in key sub-groups, such as those with immunosuppressive condition, will improve morbidity and quality of life in this population.

IntroductionChronic obstructive pulmonary disease (COPD) has been reported to have significant healthcare and economic burdens worldwide. Since the COVID-19 pandemic, there have been changes in the epidemiology of various chronic diseases. The healthcare and economic burden of severe acute exacerbation COPD (AECOPD) and the factors affecting the burden should be assessed in the post-pandemic era. MethodsA territory-wide study was conducted in Hong Kong to study the healthcare and economic burden of severe AECOPD from 2022 to 2024, and identify factors associated with an increase in the direct healthcare costs related to severe AECOPD. Adult patients with severe AECOPD admitted to the acute medical unit managed by the Hong Kong Hospital Authority from 2022 to 2024 were included. The primary outcome was the total headcount and admission numbers related to severe AECOPD, as well as the direct healthcare costs associated with severe AECOPD. The secondary outcomes included factors associated with increased direct healthcare costs resulting from severe AECOPD. ResultsFrom 2022 to 2024, there were 11,465 COPD patients admitted to acute medical hospitals for severe AECOPD, contributing to 25,053 hospital admissions and 150,717 bed days. The total direct healthcare cost was HKD $1.259 billion for these severe AECOPD. There was a significant increase in the severe AECOPD admission numbers over the 3 years. While the phenotype by baseline BEC did not affect the annual total healthcare costs related to severe AECOPD, patients with co-existing bronchiectasis had significantly higher annual number of severe AECOPD and annual direct healthcare costs. The annual number of severe AECOPD significantly correlates with total direct healthcare costs and annual direct healthcare costs related to severe AECOPD. ConclusionsSevere AECOPD carries a significant burden towards healthcare system. Patients with bronchiectasis and more frequent severe AECOPD were factors associated with a higher number of severe AECOPD episodes and the associated direct healthcare costs.

BackgroundThere are known delays to diagnosis for diseases which commonly present with chronic breathlessness, but the subsequent impact is unknown. For adults presenting with breathlessness, we investigated the time taken to achieve an explanatory diagnosis, and associations with unplanned hospitalisation and mortality. MethodsA retrospective cohort study using the UK CPRD was conducted involving adults with a first-recorded code for breathlessness and no pre-existing cardiorespiratory disease. We documented whether an explanatory diagnosis was recorded after the first code of breathlessness within two years and during all follow-up, and the time to diagnosis. Cox regression (adjusted) was used to investigate the associations with unplanned hospitalisation and mortality. Results101369 adults were included with a first-recorded code for breathlessness. After two-years, 43394 (43%) adults received a recorded explanatory diagnosis and had a higher risk of unplanned hospitalisation (1.25 [1.19-1.31]) and mortality (2.06 [1.60-2.65]) compared to adults without a diagnosis. Overall, 66909 (66%) adults received a recorded diagnosis during a median of 5-years follow-up. Adults that received a recorded diagnosis after [&ge;]6 months had worse outcomes of unplanned hospitalisation (6-24 months: 1.01 [0.94-1.08]; [&ge;]24 months: 1.13 [1.06-1.20]) and mortality (6-24 months: 3.38 [2.21-5.18]; [&ge;]24 months: 10.80 [7.46-15.70]). ConclusionWe describe a sub-group of adults coded for breathlessness but without an explanatory diagnosis with better outcomes. However, in adults with an explanatory diagnosis waiting beyond six months was associated with worse outcomes. Diagnostic pathways for chronic breathlessness need to differentiate between these two groups and achieve earlier diagnosis in those at higher risk. Key messagesO_ST_ABSWhat is already known on this topic?C_ST_ABS< Delays to diagnosis exist for chronic cardiorespiratory diseases, but the impact of these delays on future hospitalisation and mortality risk are unknown. What this study adds< Over a median follow-up of 5 years, 1 in 2 people with breathlessness had an unplanned hospital admission and 11% died. < We identify a group of patients with a breathlessness code who did not receive a diagnosis but overall had better outcomes than those with an explanatory diagnosis. < We also report novel findings that for adults who receive an explanatory diagnosis for breathlessness, waiting beyond six months to receive a diagnosis is associated with an increased risk of future unplanned hospital admission and all-cause mortality. How this study might affect research, practice or policy< Further research is needed to prioritise investigations early for patients presenting with chronic breathlessness with increased risk of underlying cardiorespiratory disease. < Diagnostic breathlessness pathways may improve the time to diagnosis and therefore improve longer term outcomes. < Where an underlying causative diagnosis of cardiorespiratory disease is not identified, outcomes appear better, and attention can be focused on reassurance and symptom management.

BackgroundAlthough predominantly preventable and treatable, chronic obstructive pulmonary disease (COPD) is a leading cause of death globally. Guidelines for managing the condition are widely available, yet COPD care remains suboptimal in many settings, including high and middle-income countries (HICs and MICs). Several approaches are used to diagnose and manage COPD, resulting in substantial variation in its care pathways. This study aimed to explore how barriers to optimal COPD care vary across HICs and MICs by identifying common and unique barriers to COPD care in six countries to inform global policy initiatives for better care while addressing specific challenges. MethodsBased on international and national guidelines, we mapped COPD care pathways for Australia, Spain, Taiwan, Argentina, Mexico, and Russia. Country-specific pathways were populated with published epidemiological, health economic, and clinical data identified through a pragmatic literature review. Semi-structured interviews with 17 respiratory care clinicians further informed and validated the pathways, data inputs, and key issues arising in each country. Thematic content analysis was used to analyse common and unique barriers across countries. ResultsSix themes were common in most HICs and MICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations"; "Limited access to specialised care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for MICs. HICs and MICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and specialised care availability. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. MICs also grapple with resource limitations and healthcare infrastructure challenges. ConclusionMany challenges to COPD care are the same in both HICs and MICs, underscoring the pervasive nature of these issues. While country-specific issues require customised solutions, there are untapped possibilities for implementing global respiratory strategies that motivate countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritisation of COPD to secure the essential resources it requires.

BackgroundSocial deprivation impacts chronic disease and acute admission outcomes. In interstitial lung disease (ILD), prior British Thoracic Society registry data for idiopathic pulmonary fibrosis has shown high deprivation was associated with poorer long-term outcomes. However, its impact on acute admissions in ILD is not known. MethodsWe undertook a multicentre, retrospective study of ILD-related admissions between 1st January 2017 and 31st December 2019 across 11 hospitals in the North West of England, utilising available real-world data. We determined social deprivation geographically by the 2019 English Indices of Deprivation deciles. The primary outcome was 90-day all-cause mortality. Results999 admissions met the inclusion criteria. 327/999 (32.7%) of admissions came from individuals geographically in the most deprived 20%. Across 999 admissions, in unadjusted survival analysis we observed a non-linear relationship between deprivation and 90-day all-cause mortality. In complete case multivariate modelling, deprivation demonstrated borderline significant association with all-cause mortality (HR 1.038, 95% CI 1.00 - 1.077, p = 0.050). However, this effect was lost in pooled analysis using multiple imputation (HR 1.001, 95% CI 0.971 - 1.033, p = 0.928). Male sex and pre-admission long-term oxygen were consistently associated with increased 90-day all-cause mortality across both models. Lower TLCO values were significantly associated with increased 90-day mortality in pooled analysis. ConclusionWe observe a high burden of acute ILD-related hospital admission amongst the most deprived 20%, suggesting geographical deprivation may impact acute healthcare seeking behaviours. Once admitted, the impact of deprivation appears more complex and multifactorial. Further studies which assess geographical and individual-level deprivation are needed to validate our findings. Key Messages What is already known on the topic?The British Thoracic Society idiopathic pulmonary fibrosis registry has previously demonstrated that higher social deprivation is associated with worse long-term outcomes. In other respiratory diseases, social deprivation impacts acute admission patterns and outcomes. What this study addsTo the best of our knowledge, this is the first study examining the relationship between social deprivation and acute ILD-related admission outcomes. This study demonstrates high acute admission burden from the geographically most deprived 20%. Once admitted, the association between geographical social deprivation and mortality outcomes appears complex and multifactorial in our modelling. How this may affect research, practice or policyThis study highlights the acute admission burden from highly deprived communities and the need for additional research to further understand the individual-level and geographical-level deprivation patients with ILD experience. We suggest the need for community outreach to build trust with deprived communities, alongside increasing awareness amongst patients, caregivers and primary care physicians in such communities. Deprivation must remain an important consideration in any new service or intervention to prevent worsening of health inequalities.

BackgroundThe prevalence of COPD is increasing with age. However, the effects of age-dependent decline in lung function on diagnosis and treatment of COPD in nonagenarians are uncertain. ObjectivesTo determine performance of spirometry, prescription of COPD medications, and COPD-related acute care visits and hospitalizations in patients 90 years and older with physician-diagnosed COPD. MethodsHealth records of 166 consecutive patients 90 years and older with physician-diagnosed COPD at a university-affiliated medical center in Chicago were reviewed. Pertinent demographic, clinical, and physiological data were extracted. ResultsPatients were predominantly ex-smoker (96%), African American (52%) males (96%). Sixty patients (36%) had no spirometry testing on record. Of the remaining 106 patients, 11 (10%) had baseline FEV1/FVC[&ge;]0.70, 24 (23%) had post-bronchodilator FEV1/FVC [&ge;]0.70, 28 (26%) had FEV1/FVC <0.70 and [&ge;]LLN, and 43 (41%) had FEV1/FVC <0.70 and <LLN. Thus, only 71 of 166 patients 90 years and older (43%) fulfilled the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations. Nonetheless, COPD medications, predominantly short-acting {beta}2 agonists and long-acting muscarinic antagonists, were prescribed to 95 of the 166 patients (57%). No significant differences in prevalence of co-morbidities and prescribed COPD medications, including systemic corticosteroids and anti-infectives prescribed during unscheduled healthcare visits and hospitalizations, were found between the four groups. ConclusionsThese data suggest that a large proportion of nonagenarians at our medical center are overdiagnosed with and treated for COPD. A larger, multi-center, prospective study is warranted to support or refute these retrospective observations.

IntroductionLenusCOPD has been co-designed to enable digital transformation of COPD services for proactive preventative care. Patient-facing progressive web application, clinician dashboard and support website integrate patient-reported outcomes (PROs), self-management resources, structured clinical summary, wearable and home NIV data with asynchronous patient-clinician messaging. We commenced the implementation-effectiveness observational cohort RECEIVER trial in September 2019, with the primary endpoint of sustained patient usage and secondary endpoints including admissions, mortality, exacerbations, service workload and quality of life. We paused recruitment in March 2021 and provided LenusCOPD as routine care in the "DYNAMIC-SCOT" COVID-19 response service scale-up. Methods83 RECEIVER trial participants and 142 DYNAMIC-SCOT participants had completed minimum 1 year follow-up when we censored data on 31st August 2021. We established a control cohort with 5 patients matched per RECEIVER participant from de-identified contemporary routine clinical data. ResultsSustained patient app utilisation was noted in both cohorts. Median time to admission or death was 43 days in control, 338 days in RECEIVER and 400 days in DYNAMIC-SCOT participants who had had a respiratory-related admission in the preceding year. The 12-month risk of admission or death was 74% in control patients, 53% in RECEIVER and 47% in the DYNAMIC-SCOT sub-cohort participants. There was a median of 2.5 COPD exacerbations per patient per year with stable quality of life across follow up and a manageable workload for clinical users. ConclusionsA high proportion of people continued to use the co-designed LenusCOPD application during extended follow-up. Outcome data supports scale-up of this digital service transformation. Key messages What is the key question?Can sustained patient interaction and improved patient outcomes be achieved with digital transformation of a COPD service? What is the bottom line?Participants continue to use the LenusCOPD patient app, with an average of 3-3.5 interactions per person per week sustained >1-year post-onboarding. COPD- related hospital admissions and occupied bed days were reduced following LenusCOPD onboarding in participants with a history of a severe exacerbation in the previous year, with a median time to readmission of 380 days compared with 50 days in a contemporary matched control patient cohort. Why read on?Feasibility and utility results support scale-up adoption of these digital tools, to support optimised co-management of COPD and other long-term conditions within a continuous implementation-evaluation framework. This will establish a test-bed infrastructure for additional innovations including artificial intelligence-insights for MDT decision support.

ObjectiveProcess evaluation of the Yorkshire Enhanced Stop Smoking (YESS) study intervention, to provide evidence regarding optimal integration of smoking cessation support within lung cancer screening (LCS). DesignMixed-methods process evaluation. SettingYESS was a Randomised Controlled Trial testing the effect of personalised smoking cessation support, integrated within LCS. YESS study participants were recruited from the Yorkshire Lung Screening Trial. Participants/data collectionSemi-structured interviews with 45 trial participants and eight SCPs 4, 12 and 52-weeks after screening (participants) or training (SCPs). Thematic analysis to assess intervention exposure, context, contamination and theory. Observations of SCP consultations on the screening unit (n=84; 4%) and 4-weeks after screening (n=132; 13%) tested intervention fidelity. InterventionThe YESS study tested opt-out, co-located standard best practice (SBP) smoking cessation support (control) versus a theory-informed personalised risk information booklet designed to increase efficacy beliefs in addition to SBP (booklet intervention), delivered by trained smoking cessation practitioners (SCPs). ResultsIntervention context was paramount: participants in both trial arms described benefits of co-located and ongoing high-intensity smoking cessation support, with immediate provision of pharmacotherapy. Tailored, non-judgemental care was considered key to initiating and sustaining quitting, particularly for participants at various points along their quit or those awaiting their scan result. Fidelity was high (98%) and moderate (75%) for SBP, moderate (77%) for the booklet intervention. Exposure varied by participants needs, including their screening results. Potential contamination was observed, with SCPs delivering elements of the booklet intervention training across both trial arms. ConclusionsA personalised approach is critical to supporting smoking cessation in LCS. Harnessing the benefits of LCS for supporting cessation at the time of screening requires investment in specialist practitioners to deliver person-centred smoking cessation support. Trial registration. www.clinicaltrials.gov/study/NCT03750110 Putting research into contextO_ST_ABSWhat is already known on the topicC_ST_ABSO_LIIntegrated smoking cessation in lung cancer screening is recommended due to the additive benefits of screening participation and cessation on lung cancer mortality. C_LIO_LIExisting evidence supports the provision of higher-intensity smoking cessation interventions within lung cancer screening, such as immediate smoking cessation support at screening, with multiple sessions of behavioural counselling and/or pharmacotherapy. C_LIO_LIHowever, there is currently no consensus about the optimal high-intensity model to support smoking cessation using behavioural science principles within lung cancer screening. This is a major priority for research, practice and policy. C_LI What this study addsO_LIWe provide evidence for the benefits of co-located and longer-term (up to 12-weeks in person and remote) person-centred support, delivered by trained specialist lung screening SCPs, regardless of trial allocation. C_LIO_LIFuture implementation of smoking cessation embedded in lung screening may benefit from investment in specialist lung screening SCPs, adopting a flexible, person-centred approach to the offer and delivery of SBP smoking cessation support. C_LI

IntroductionRadiological change which may be attributed to infection can also be attributable to lung cancer. Patients with SARS-CoV-2 infection can develop groundglass lung opacification which may result in chronic lung changes. Current British Thoracic Society (BTS) guidelines recommend patients with pneumonia and COVID19 undergo repeat chest radiography. MethodsA single-centre audit of patients hospitalised with community-acquired pneumonia or COVID19 over three time periods during the COVID19 pandemic (Aug-Dec 2020, Jun-Aug 2021, Dec-Jan 2022). We assessed whether patients were eligible for radiological follow-up and if repeat radiological investigation occurred. Results1040 adults were hospitalised with infective radiological change (pneumonia=596, COVID19=444). 831/1040 patients (80%) required radiological follow-up under BTS guideline criteria: there was minimal difference between the first two time periods studied. Patients hospitalised with CAP were less likely to have radiological follow-up planned than those admitted with COVID19 disease (49% versus 59% respectively). Following a change in hospital policy, follow-up rates increased to 69% and 71% for pneumonia and COVID19. Overall, only 47% eligible patients received follow-up in line with current guidelines. ConclusionBTS guideline adherence is important to avoid delay in diagnosing underlying malignancy or chronic lung disease. Radiological follow-up following CAP and COVID19 may be suboptimal, with a paucity of data. Follow-up arranged under the hospital team was more likely to occur than when the GP was responsible for instigating repeat radiological imaging. Further investigation into rates of radiological follow-up should be undertaken, including reasons for non-adherence, to ensure patients receive appropriate treatment following respiratory infection.

BackgroundPulmonary rehabilitation(PR) is a highly effective intervention for people with chronic respiratory disease, however it is not known how best to sustain its benefits. Clinical trials are needed to establish if participation in Singing for Lung Health(SLH) groups following PR will improve health-related quality-of-life, healthcare utilisation and exercise capacity compared to usual care. A feasibility study would help to guide development of these. MethodsIn a multi-centre, mixed-methods randomised controlled feasibility trial, PR participants at 4 sites, were pre-screened at baseline assessment. An SLH taster session was included routinely as part of the PR programmes. Eligible PR completers were invited to take part in the trial and randomised to usual care or a 12-week SLH course. Feasibility outcomes included recruitment rate, intervention compliance (at least 8/12 sessions) and completeness of data collection including symptom questionnaires, walk tests and physical activity monitoring. Interviews with participants and study personnel about their experience and views of the study were subjected to thematic analysis. ResultsBetween October 2022 and November 2023, 1311 patients were assessed to start PR, 838 completed. Of those completing, 243 were ineligible to take part, (predominantly due to vaccination status and other primary PR diagnoses), and 531 declined. 64 people (33 female, mean(SD) age 69(12), 41 ethnically white, COPD/asthma/interstitial lung disease/bronchiectasis n=33/16/9/6) were recruited with 30(93.8%) SLH and 29(90.6%) controls completing the study. 20(62.5%) of the SLH group completed at least 8/12 SLH sessions. There was enthusiasm for a definitive trial from participants, clinicians and singing group leaders perspectives based on positive experiences of trial involvement. Improvements to recruitment strategy, intervention structure, outcome measures and staffing were suggested. ConclusionA definitive RCT of SLH post-PR appears feasible, with acceptable uptake and completion rates. Trial RegistrationISRCTN11056049 What is already known on this topic?Singing for Lung Health(SLH) has previously been shown to improve health-related quality-of-life for people with Chronic Obstructive Pulmonary Disease. Pulmonary Rehabilitation is a gold standard intervention, but it is not known whether SLH groups can be delivered as a maintenance programme after PR completion, or whether an RCT comparing this approach to usual care is feasible. What this study addsIt is feasible to conduct an RCT investigating the clinical and cost effectiveness of a 12-week SLH post PR maintenance programme compared with usual care. How this might affect research, practice or policyThis study will inform the design and delivery of a definitive RCT. The feasibility methodology used in this study can be applied to other creative health interventions which may be considered as maintenance options post-PR.

ObjectivesFunctional limitation from COPD manifests more from physical rather than respiratory impairment. To what extent health access affects the functional limitation among individuals with COPD is yet to be known. This study aims to assess the relationship between healthcare access and functional limitations among individuals with COPD. Study DesignRetrospective analysis of a cross-sectional population-based survey MethodsThis study pooled 11-year (2008 - 2018) data from the Integrated Public Use Microdata Series - National Health Interview Survey (IPUMS-NHIS). We restricted the data to respondents with self-reported COPD, aged 40 years and older. The independent variables were sociodemographic and behavioral characteristics. The exploratory variables were measures of healthcare access - healthcare coverage, delayed appointment, affordable care, and a usual place for care. The outcome variable was the presence or absence of functional limitations. ResultsThe age, race, educational attainment, marital status, smoking status, and poverty-income ratio had a significant association with functional limitation (p<0.001) We found statistically significant associations between functional limitation and healthcare coverage, delayed appointment, affordable care, and a usual place for care. Poverty modified the relationship between functional limitations and the four measures of healthcare access, with the odds of functional limitation increased among the poor with no healthcare coverage, delayed appointment, unaffordable care, and no usual place for care. ConclusionsA strong relationship exists between the quartet of healthcare coverage, delayed appointment, affordable care, and usual place for care and self-reported functional limitation among individuals with COPD. Poverty was an effect modifier, with the odds of functional limitation worse among the poor.

TitleA scoping review of the unmet needs of patients diagnosed with idiopathic pulmonary fibrosis (IPF). AimsPatients diagnosed with IPF have a high symptom burden and numerous needs that remain largely unaddressed despite advances in available treatment options. There is a need to comprehensively identify patients needs and create opportunities to address them. This scoping review aimed to synthesise the available evidence and identify gaps in the literature regarding the unmet needs of patients diagnosed with IPF. MethodsThe protocol for the review was registered with Open Science Framework (DOI 10.17605/OSF.IO/SY4KM). A systematic search was performed in March 2022, in CINAHL, MEDLINE, Embase, PsyhcoInfo, Web of Science Core Collection and ASSIA Applied Social Science Index. A comprehensive review of grey literature was also completed. Inclusion criteria included patients diagnosed with IPF or PF; English language only and date range 2011-2022. A range of review types were included. Data was extracted using a data extraction form. Data was analysed using descriptive and thematic analysis. A total of 884 citations were reviewed. Ethical approval was not required. Results52 citations were selected for final inclusion. Five themes were identified: psychological impact of an IPF diagnosis; adequate information and education: at the right time and in the right way; high symptom burden support needs; referral to palliative care and advanced care planning (ACP) and health service provision-a systems approach. ConclusionThis review highlights the myriad of needs patients with IPF have and highlights the urgent need for a systems approach to care, underpinned by an appropriately resourced multi-disciplinary team. The range of needs experienced by patients with IPF are broad and varied and require a holistic approach to care including targeted research, coupled with the continuing development of patient-focused services and development of a clinical care programme.

IntroductionProfessionals other than Physicians are commonly employed to evaluate patients with possible sleep apnoeas worldwide, but less so in the UK. This study evaluates a novel Nurse Specialist led sleep diagnostic pathway. MethodsA sample of patients treated in the novel, Nurse led, pathway were compared to a group treated in a more conventional, Consultant led, setting. ResultsThe use of a Nurse led pathway significantly reduced time from referral to CPAP set up (56 days) compared to the Consultant led pathway (213.5 days) with comparable outcomes in terms of CPAP compliance and symptom improvement. ConclusionThe use of a Nurse led sleep diagnostic pathway significantly reduces waiting times, whilst maintaining appropriate clinical standards.