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Poster Presentations

Introduction: A new service for the supply of oxygen therapy to patients at home started on 1 February 2006. Patients in England and Wales are supplied by four companies (Air Products, Allied Respiratory, BOC and Linde). These companies have agreed to provide anonymised data on patients to the BTS Home Oxygen database committee.

Methods: Data on patients with active orders in June 2007 were supplied. Patient’s service category data were excellent with only 33 missing records, and of these 27 had data on modality of supply, hours of use and litres of oxygen prescribed. Similarly, only 866 postcodes were possibly erroneous as they were unlinkable to the Office of National Statistics Postcode Directory File for February 2007. Another well-completed data field from the HOOF forms was date of birth; only 1045 records were missing and 118 obviously erroneous. NHS numbers were missing for 8107 records and another 8732 were not 10 characters in length. For three contractors, clinical diagnosis codes were present in only 29% of records. The number of patients in age groups 0, 1–4, 5–9, 10–14, etc and 85+ plus were counted after eliminating possible duplication of patients and linked to the most recent (2005) quinary mid-year residential populations estimates from the Office of National Statistics website (http://www.statistics.gov.uk).

Results: There were 76 753 home oxygen users, 3136 (4.1%) were paediatric patients aged below 17 years. The commonest age for home oxygen was 77 years (range 0–107). Prevalence fell from 0.73 per 1000 in the under 1 years to 0.58 per 1000 in the 1–4 year olds and remained constant at about 0.11–0.12 per 1000 until at about 45 years, when prevalence started to rise to a peak of 8.8 per 1000 in the 80–84 and 85+ age groups.

Conclusions: The BTS Home Oxygen database has been established and preliminary analysis shows adequate data collection. We have been able to establish for the first time the prevalence of Home Oxygen use in England and Wales. Prescribers are encouraged to carefully complete the clinical diagnosis information in question 14 of the HOOF form.

Funding: Funded by the Department of Health.

DO CURRENT BTS GUIDELINES FOR AIR TRAVEL CORRECTLY IDENTIFY PEOPLE WITH THORACIC SCOLIOSIS WHO BECOME HYPOXAEMIC (PAO₂ <6.6 KPA) ON HYPOXIC CHALLENGE TESTING?
D. Bandyopdhyay, T. Quinnell, J. M. Shneerson, I. E. Smith. The Respiratory Support and Sleep Centre, Papworth Hospital, UK

Introduction: The BTS guidelines for flight assessment, largely based on evidence from people with COPD, recommend: no additional oxygen for air travel if the resting oxygen saturation (SpO₂) is >95% and hypoxic challenge testing (HCT) for people with an additional risk factor, if the SpO₂ is between 92–95%. In the summary for primary care, a walking distance of greater than 50 m without distress is suggested as reassuring and can obviate the need for an HCT. There are only anecdotal data relating to spinal deformity. We assessed these recommendations in people with primary, thoracic scoliosis.

Methods: People with thoracic scoliosis of varying severity were recruited to the study. Resting SpO₂ and arterial blood gases (ABGs) breathing room air, spirometry and shuttle walking test distance (SWT) were measured. All subjects underwent an HCT breathing an FiO₂ of 15% for 15 minutes, or until SpO₂ fell below 85%, when ABGs were taken.

Results: Values are reported as means (SD) unless otherwise stated. Twenty people (11 female) with thoracic scoliosis aged 65 (9.9) years, were studied. The Cobb angle was 89 (31.4)°. Thirteen were on home nocturnal non-invasive ventilation (NIV), none used additional oxygen. The mean FEV₁ and vital capacity were 0.8 (0.39) and 1.14 (0.42) l respectively, SpO₂ was 93 (2.6) %, PaO₂ 9 (1.1) kPa and PaCO₂ 6.1 (0.44) kPa. The SWT distance was 262 (121) m. HCT was positive in 14 subjects (PaO₂ <6.6 kPa), negative in 2 (PaO₂ >7.4 kPa) and 4 had intermediate results. The walking distance bore no relation to the HCT result, all walked over 80 m. Eight of the 14 subjects with a positive HCT had a resting SpO2 greater than 95%. The use of home NIV did not predict the HCT outcome.

Conclusions: Despite a normal daytime SpO₂ and fair exercise tolerance subjects with thoracic scoliosis may desaturate profoundly on an HCT. The current BTS guidance for air travel does not identify these people, who are at risk of severe hypoxaemia. There should be a low threshold for performing HCTs on people with scoliosis before giving them advice on air travel.

AN AUDIT OF OXYGEN USE IN EMERGENCY AMBULANCES AND IN A HOSPITAL EMERGENCY DEPARTMENT
K. E. Hale, B. R. O’Driscoll. Salford Royal Foundation Trust, UK

Background: Oxygen use in emergency medicine is important but poorly studied. It is not known how many patients receive oxygen in emergency ambulances or in emergency departments (EDs) in the UK. Patients with COPD are especially vulnerable to inappropriate oxygen therapy.

Methods: An audit proforma was used in the "majors" sector of a university hospital ED to look at use of oxygen in ambulances and in the ED. 1022 patients were studied in May and June 2007.

Results: (1) 921 patients (90% of all patients) had SpO2 recorded in the ambulance. (2) 159 patients (17%) had saturation <94% at some time in the ambulance. (3) 62 patients (7%) had an oxygen saturation <90% at any time, including 14 COPD patients. (4) 48 of 878 non-COPD patients (5%) had saturation <90% at any time. (5) 34% of patients arriving in the ED majors section had received oxygen in the ambulance. Of this group, almost half had oxygen therapy discontinued in the ED. (A further 3% of patients received Entonox, a mixture of oxygen and nitrous oxide). (6) Only 5% of patients had oxygen started de novo in the ED. (7) 62% of oxygen use in ambulances was in line with JRCALC guidance (Joint Royal Colleges Ambulance Liaison Committee). Most of the "breaches" involved the use of medium dose oxygen for non-hypoxic patients where current JRCALC guidelines specify high dose oxygen. (8) Of 43 patients with a diagnosis of COPD, only 58% were correctly identified in the ambulance. (9) 60% of COPD patients had saturation below 94% at some time and 33% fell below 90%. (10) All COPD patients who received oxygen were treated with simple face masks. 8% had an oxygen flow of 2 l/min (about 28% oxygen), 19% had 4 l/min (35–40%) and 73% had >4 l/min (>40% oxygen). The simple face mask is not designed for use at flow rates below 5 l/min because of the risk of re-breathing and increased resistance to inspiration. Therefore none of the COPD patients received appropriate oxygen therapy.

Conclusions: Oxygen is widely used in emergency ambulances in Salford. (34% of patients would translate to about 2 million episodes of emergency oxygen use in UK ambulances each year). About 33% of COPD patients and 5% of non-COPD patients had clinically significant hypoxaemia (saturation below 90% at any time). 42% of patients with COPD were not categorised as having COPD during ambulance transfers and most of those with recognised COPD were given more than 28% oxygen. The BTS has commissioned a national guideline for emergency oxygen use which will be published in late 2007.

RESPIRATORY ASSESSMENT CENTRE: A NOVEL WAY TO HANDLE RESPIRATORY EMERGENCIES IN A LARGE TEACHING HOSPITAL
C. J. Warburton, L. Davies, S. Agarwal, R. Angus, T. Jagoe. Aintree Chest Centre, UK

During the winter pressure period of 2006/7 the Aintree Chest Centre piloted a novel Respiratory Assessment Centre (RAC). This comprised a 14 bedded acute assessment area alongside the general MAU. The RAC was staffed from 09:00 to 17:00 seven days a week by two F2/ST1s, a respiratory specialist registrar and a consultant physician (for a month at a time in rotation). Respiratory nurse specialists also covered the unit on a rotational basis. Patients with respiratory conditions from the acute medical take were seen and assessed first by the RAC team who undertook two ward rounds per day and thence either discharged or admitted. A management plan was instituted wherever the patient was subsequently admitted.

Over the first four months a mean of 111 patients was assessed each week in the RAC, with a discharge rate of 31%. The number of COPD patients using our community based "hospital at home" team increased by 80% (mean 25 to 45 per month) from the comparable period in 2006. Overall, average length of stay for COPD fell from mean (SD) 7.9 (9.6), median 6 days to 7.0 (8.13), median 4 days (data from 2005/6 and 2006/7) The average length of stay on the chest wards fell for one ward area (36 beds) and remained static for the others (total 55 beds). Despite our best efforts only 70% of patients seen in the RAC had respiratory conditions, the remainder having general medical conditions. Patients in the general MAU with respiratory conditions were also seen by the RAC senior staff upon request.

We feel that the RAC improved the quality of care given to patients with respiratory disease within our Trust. Measures of service activity and outcomes also appear favourable. A critical mass both of respiratory admissions and respiratory physicians is required for this pattern of working; however by rotating this work between all respiratory physicians, career progression issues are avoided. The RAC model appears to be a viable way to deliver very early specialist input for patients presenting with respiratory disease to large hospital Trusts and offers advantages over the traditional MAU model.

SHOULD ALL CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS WITH CARDIAC COMORBIDITIES HAVE AMBULATORY OXYGEN ASSESSMENT?
E. Tabiowo, L. Kemp, K. Morgan, J. Edge, V. Clarke, R. K. Kedia. Mid-Cheshire Hospital NHS Trust, UK

Introduction: Ambulatory oxygen refers to the provision of oxygen therapy during exercise and while performing activities of daily living. Current BTS guidelines on oxygen assessment indicate that ambulatory oxygen therapy is not recommended in patients with chronic lung disease and mild hypoxaemia (not on long-term oxygen therapy (LTOT)), no exercise-induced desaturation (EID) and patients with chronic heart failure.

Design and Objective: We carried out a prospective, observational study to assess the effect on ambulatory oxygen assessment and outcome in patients with COPD and cardiac comorbidities.

Material and Method: Thirty three COPD patients, who attended the oxygen assessment clinic at Mid-Cheshire Health Trust between February 2006 to October 2006, were included in the study. All patients had their spirometry measured, baseline arterial blood gas measurement, six-minute walk test (6MWT), and further LTOT assessment where necessary. Patients were divided into mild (FEV₁ 50–80%), moderate (FEV₁ 30–49%) and severe (FEV₁ <30%) COPD based on the NICE criteria using the FEV₁ predicted percentages. EID was deemed significant if there was a greater than 4% drop in oxygen saturation from baseline to a value level below 90%, in line with the BTS guidelines.

Results: Thirty three COPD patients assessed during the periods of February and October 2006 were included. 9 patients had mild COPD, 16 patients had moderate COPD, and 8 patients had severe COPD. On ambulatory oxygen: 4 (44.4%), 6 (37.5%) and 5 (62.5%) patients demonstrated significant EID in mild, moderate and severe group respectively. Further analysis of the mild group showed that 3 out of 4 (70%) patients who desaturated also had associated congestive cardiac failure (CCF) and/or ischaemic heart disease (IHD) as comorbidities. This is compared to 1 out of 5 (20%) patients who did not desaturate in the mild group. The mean PaO₂ in the mild COPD subgroup was 8.03 kPa, with 2 of the 9 patients (22.2%) having a PaO₂ less than 7.3 kPa (thereby meeting the LTOT criteria). Mortality during the follow-up period was 22.2% (2 patients) in the mild group and 6.3% (1 patient) in the moderate group. No deaths were recorded in the severe group during this period. Both deaths in the mild COPD group were in patients who also suffered from CCF. The only death in the moderate group was a patient who suffered from lung cancer.

Conclusions: This observational study shows that patients with mild COPD and cardiac comorbidities, can show significant levels of EID on ambulatory oxygen assessment, regardless of their PaO₂. Hence, despite minimal airflow limitation, the presence of cardiac co-morbidities such as CCF necessitates the need for ambulatory oxygen assessment that can be beneficial to this patient group. We recommend that all patients with COPD with cardiac co-morbidities should be assessed with 6MWT for EID. In patients with EID, we recommend that further assessment for pulmonary hypertension with echocardiography be carried out, in addition to the prescription of ambulatory oxygen therapy.

AUDIT REVIEWING THE IMPACT OF LUNG ALERT CARDS AND AMBULANCE CREW EDUCATION ON INAPPROPRIATE OXYGEN PRESCRIBING IN PATIENTS WITH COPD
A. L. Kerry¹, C. Lobo¹, S. Milanes¹, J. Curtis¹, N. A. Maskell¹. ¹North Bristol Lung Unit, Southmead Hospital; ²Hawkes Bay Hospital

Background: Some COPD patients are sensitive to rises in inspired oxygen concentrations which may lead to CO2 retention and acute type 2 respiratory failure (T2RF). The JRCALC/ASA Ambulance Services Guidelines recommend that "known T2RF patients should be encouraged to carry some form of identification to aid in their care". Due to the perception that high numbers of COPD patients were being admitted to hospital having had inappropriate oxygen administration, it was decided to audit this before and after the introduction of patient held "Lung Alert Cards" and education of the local Ambulance Service in oxygen administration in COPD.

Method: We identified patients admitted over two three-month periods January–March in 2005 and 2006 with a diagnosis of exacerbation of COPD on discharge or death and randomly selected 100 of these admissions and pulled the notes. Data were then extracted from the notes. We assessed oxygen administration by ambulance crew, incidence of acute T2RF, use of non-invasive ventilation (NIV) on arrival to hospital and length of stay (LOS).

Notes were available for review in 73/100 episodes (see table). The incidence of acute T2RF on admission fell from 31% in 2005 to 17% in 2006. The need for NIV in the first 24 h of admission also fell from 27% in 2005 to 14% in 2006. LOS was also one day less in 2006 compared to 2005.

Conclusion: The strategies employed to reduce oxygen toxicity in COPD patients coming to hospital—Lung Alert Cards and ambulance crew education—were associated with a reduction in the amount of inappropriate oxygen administration in ambulances, a fall in the incidence of type 2 respiratory failure and a reduction in need for NIV.

ASSESSMENT FOR AMBULATORY OXYGEN REQUIREMENT IN PATIENTS WITH COPD USING THE 6-MINUTE WALK TEST
L. A. E. Brown, P. J. Ryan. Hereford County Hospital, UK

Background: Six-minute walk tests (6MWT) are commonly used to assess the need for ambulatory oxygen for patients with COPD. It is not clear which parameters should be measured during a 6MWT and which are the most important for assessing the need for ambulatory oxygen. We retrospectively analysed 67 6MWTs in patients with COPD.

Methods: All patients attending our respiratory physiology department for 6MWTs between 2002 and 2006 were identified from the filed assessment forms. Patients had been referred for ambulatory oxygen assessment either directly from the chest clinic or as part of an assessment following admission for an acute exacerbation of COPD. The diagnosis of COPD was made by the respiratory team and confirmed with spirometry. All patients underwent the same protocol of unblinded 6MWT in air, followed by 10 min rest, and then a repeat test while wearing nasal oxygen delivered at 2 l/min. Resting oxygen saturation, minimum oxygen saturation during exercise, recovery time (return to resting oxygen saturation), exercise distance and Borg score were recorded both on and off oxygen. Oxygen saturation was measured using a Pulseox-7 pulse oximeter. All patients had spirometry but only some had transfer factor measured.

Results: Of the 67 patients 35 (52%) were male. The mean age was 70.6 years (SD = 10.4 years). The mean FEV₁ was 0.84 l/m (SE 0.05) and mean % predicted FEV₁ was 37.9 l/m (SE 2.2). The mean FVC was 2.0 l/m (SE 0.08) and mean % predicted FVC was 67.6 (SE 2.2). On air the mean resting oxygen saturation fell from 93.2% to 86.8% with a mean exercise distance of 173 metres (SE 10.5), recovery time of 87 seconds minutes and Borg score of 3.3. The fall in oxygen level with exercise was strongly correlated to the resting oxygen level (r = 0.69, p<0.01) but none of the lung function measures except FVC. On oxygen the mean resting oxygen saturation fell from 96% to 91.5% with a mean exercise distance of 201 metres (SE 11.3), recovery time of 70.5 seconds and Borg score of 3.3. The mean improvement in exercise distance on oxygen was 28 m (SE 3.0, range –34 to 84 metres). Bivariate analysis showed that the improvement in exercise distance on oxygen was significantly correlated to fall in oxygen saturation with exercise in air, though this correlation was not strong (r = 0.265, p = 0.03). This is shown in the figure.

Conclusion: When measuring oxygen desaturation and exercise distance by the 6MWT in patients with COPD, there was a heterogeneous response poorly predicted by spirometric lung function testing and strongly correlated with resting oxygen saturation. For patients with COPD the fall in oxygen saturation during a six-minute walk test in air, only correlates weakly with the improvement in exercise distance when repeated on oxygen. Whether the prescription and subsequent usage of ambulatory oxygen in these patients can be predicted by measures recorded in the 6MWT is a question for an ongoing study.

APPROPRIATENESS OF EMERGENCY OXYGEN THERAPY FOR COPD PATIENTS
J. W. Dodd, H. C. Tribe, D. M. Halpin. Royal Devon & Exeter Hospital, UK

Introduction: Nearly a quarter of all patients admitted to hospitals with breathlessness have chronic obstructive pulmonary disease (COPD) of whom approximately 50% have a degree of hypercapnoea. The use of emergency oxygen therapy is thought to be both inconsistent and poorly understood. (Emerg Med J 2001;18 :333–9). Guidelines which divide management into three stages (pre-hospital, emergency department and pre-admission), have been prepared by the North West Oxygen Group (Emerg Med J 2001;18 :421–3) and the British Thoracic Society (BTS) are currently preparing national guidelines on this issue.

Aim: The primary aim of this study was to use the North West Oxygen Group guidelines to assess whether current oxygen therapy and patient assessment was optimal.

Method: A retrospective review of hospital and paramedic notes of all patients discharged with a primary diagnosis of COPD between February 2007–May 2007 from the Royal Devon & Exeter Hospital (RD&E), UK

Results: 130 cases were identified of which 70 notes were available to be reviewed by our team. Of these 53% were female, 47% male and the mean age was 71 years (range 35–94). 81% were recognised as having COPD by the ambulance team at the pre-hospital stage. 56% (39/70) were admitted via the emergency department and 41% (29/70) via the emergency medical unit, the remaining 3% of patients were admitted via the outpatients department and NHS walk-in centres. Pre-hospital stage: 1.4% of journey times to hospital were less than 15 min, most (46%) took between 30–60 min. 19 patients (27%) were given uncontrolled high flow oxygen (that is, >40%–60% (4–10 l/m), 21 (30%) were given controlled flow oxygen, 8 (11%) were managed without supplementary oxygen and in 22 cases (31%) oxygen therapy was not recorded. Emergency department assessment (ED) stage: 26% patients were seen <10 min. 49% were triaged as urgent. 21% (8/39) patients received uncontrolled high flow oxygen therapy two of whom required non invasive ventilation (NIV). 69% (27/39) were given controlled flow oxygen or room air only and 10% (4/39) oxygen therapy was not recorded. Emergency medical unit (EMU)/alternative emergency department assessment stage: 14% patients were seen <10 min but 41% waited >60 min to be seen by a doctor. 21% patients were triaged as urgent. 7% (2/29) were given high flow uncontrolled oxygen therapy of whom one required NIV. 86% (25/29) were managed with controlled flow or no supplementary oxygen. 7% (2/29) oxygen therapy was not recorded. 69% (48/70) of both ED and EMU patients had arterial blood gas (ABG) analysis 85% (41/48) of whom had their oxygen therapy titrated appropriately.

Discussion: In more urban areas of the UK most patients are transferred to hospital within 15 min. The RD&E served a mixed urban/rural population and it is suprising therefore that only 1.4% of patients reached hopital within 15 min. This is of particular concern given that almost 30% of patients potentially received inappropriately high oxygen therapy. Poor documentation was evident at all three stages of care with between 10% (in hospital) and 30% (pre-hospital) of cases without documentation of oxygen saturations or inspired oxygen therapy. Patients who appear unstable are often transferred directly to ED, which is likely to account for the difference in the percentage of patients triaged as urgent by ED and EMU. When ABGs were taken, oxygen therapy appeared to be titrated correctly on most occasions (85%), however there was a worrying delay in having a medical review, especially for patients admitted via EMU (41% patients waiting >60 min). This delay coupled with the long transit time compounds the risks posed to the patient with COPD. The use of high flow uncontrolled oxygen in hospital occurred in 13% (9/70) of patients, of this group 66% (5/9) had either no documented saturations or results >90% suggesting that they received unnecessarily high concentrations of oxygen resulting in two patients requiring NIV.

Conclusion: The use of emergency oxygen therapy in COPD patients transferred to and admitted to the RD&E differed significantly from the recommendations in the North West Oxygen Group guidelines. Particular problems arose because of long transit times, the use of uncontrolled high flow oxygen at the pre-hospital stage and delays in medical assessment. Once assessed the titration of oxygen appears to be appropriate.

SHORT BURST OXYGEN THERAPY DOES NOT RELIEVE BREATHLESSNESS AFTER EXERCISE IN PATIENTS WITH SEVERE COPD WHO ARE NOT HYPOXAEMIC AT REST
L. Mckinlay, S. Pulakal, P. M. Turkington, B. R. O'Driscoll. Hope Hospital, UK

Background: Short burst oxygen therapy (SBOT) may be ineffective in relieving breathlessness after exercise in patients with severe COPD who are not hypoxaemic at rest (O’Neill B. Respir Med 2006;100 :1129).

Methods: We studied 37 patients with severe COPD (FEV₁ <40% predicted), resting oxygen saturation of 93%. Patients undertook an exercise step test four times. After exercise, patients were given 4 l/min of oxygen from a simple face mask, 4 l/min air from a mask (single blind), air from a fan or no intervention. Pulse, rate, oxygen saturation and symptoms were monitored before, during and after exercise. Patients completed a Borg breathlessness scale (no breathlessness = 0, maximal breathlessness = 10).

Results: The mean BORG score was 1.5 at rest, and 5.1 at the end of exercise. The Borg score fell to baseline value by 4 min with no difference between the treatment groups at any time point even for the 13 patients who de-saturated below 90%. The mean time to subjective recovery (feeling same as before exercise) was 3.6 min with no difference between treatments. Mean time to pulse rate recovery was 2.6 min breathing air (95% CI 2.1 to 3.4) and 1.9 min breathing 28% oxygen (1.5 to 2.2). Patients were asked to rank the treatments for relief of breathlessness. Fifteen patients (40%) had no preferred treatment. Of the 22 patients who expressed a preference for a single treatment option, 8 preferred oxygen (22% of the entire group), 6 preferred the fan, 5 preferred room air and 3 preferred air via a mask (² p = 0.42 comparing these four preferences).

Conclusions: This study suggests that non-hypoxic COPD patients get no symptomatic benefit from oxygen therapy after exercise, even if exercise has caused de-saturation below 90%. Use of air from a mask or from a fan had no placebo effect in this study. When combined with previous smaller studies, this negative result has major organisational and financial implications for the use of SBOT in the UK and elsewhere. We would suggest that SBOT should only be considered for patients who express a clear preference for oxygen compared with air in a single-blind n = 1 study.

A REVIEW OF THE FIRST YEAR OUTCOMES OF AN OXYGEN ASSESSMENT CLINIC IN A DISTRICT GENERAL HOSPITAL
J. Creasey, K. Archer, D. Mukherjee, B. Yung, J. Samuel, A. Elsheikh, S. Lincoln. Basildon University Hospital, UK

Background: The provision of domiciliary oxygen therapy underwent significant changes in England and Wales in February 2006. Oxygen guidelines recommend optimal follow-up of patients and in response, weekly oxygen clinics were established. A review of the first three months of this service was presented in 2006 and provided evidence to support the BTS recommendations.

Aim: To review the outcome of the first year of the oxygen clinic in a 652 bedded district general hospital and to establish a local dataset which may provide evidence for a permanent oxygen assessment service within the locality.

Method: Patients prescribed oxygen on discharge were given an oxygen clinic appointment 6 weeks post-discharge. Those with oxygen requirements seen in outpatients were seen in the next available oxygen clinic. The outcome of these assessments were recorded and reviewed.

Results: 112 patients (54 male, age range 51–94 years) attended the oxygen clinic. The attendance rate was 70%. Patients with COPD (75%) and pulmonary fibrosis (22%) formed the two main diagnostic groups. Oxygen therapy was continued at its pre-existing level in 40 patients (36%). 7% had changes made to the oxygen flow rate. In 22%, oxygen orders were changed (for example, long-term oxygen therapy to short burst). In 13% oxygen therapy was either stopped or not required. Overall advice on use and alterations to treatment were made in 51%. Three patients with Type II respiratory failure were admitted directly from the clinic.

Conclusion: This review provides further evidence that oxygen assessment is an essential part of oxygen therapy as more than half of those who attended the clinic had changes made to their oxygen orders. It also highlights the potential risks to patients in the community who are left without assessment. The high non-attendance rates may be an indicator of the need for patient review in the community.

DOMICILIARY OXYGEN PRESCRIPTION FROM SECONDARY CARE: ARE WE GETTING IT RIGHT?
A. Ashish, J. Koch, S. Baird, M. Haris, P. Deegan, M. J. Walshaw. Royal Liverpool and Broadgreen University Hospital, UK

Introduction: LTOT prescription changed from GPs to hospital practitioners in 2006 and a home oxygen order form (HOOF) was commissioned. Unless given for palliative care, LTOT prescription still required hypoxaemia (PaO₂ <7.30 kPa), with a response to oxygen treatment (PaO₂ >8.0 kPa), without significant hypercapnia ("oxygen titration" study). We assessed the completion of HOOFs and the appropriateness of oxygen prescriptions from our large teaching hospital.

Methods: We analysed 123 randomly selected HOOFs (39% of those generated February 2006 to April 2007) for data completeness. From clinical records we looked at blood gas analyses performed, and whether an oxygen titration study had been undertaken.

Results: In 74 (60%), the HOOF was filled out by a respiratory team, 44 (35%) by a non-respiratory team, and in 5 (4%) the origin was unknown. COPD was the commonest diagnosis (51, 41%), then ILD (13, 10%), heart failure (7, 6%), palliative care (9, 7%), and other conditions (5, 3%): 36 (29%) had no diagnosis. PRHOs completed 62 HOOFs (50%), SHOs 11 (9%), SpRs 13 (10%), consultants 12 (10%), clinical physiologists 17 (14%), and senior nursing staff 6 (5%). Only 18 PRHO forms (29%) and none by nursing staff were correct: respiratory doctors were better than other teams (37/74 vs 10/44, ² = 8.56, p<0.01), and clinical physiologists were better than everyone else (15/17, ² = 14.0, p<0.001). Based on blood gases and palliative care prescriptions, 70 (57%) were deemed appropriate: 18 (14%) were clearly inappropriate and in 35 (30%) no blood gas analysis had been undertaken. Of 64 LTOT prescriptions, only 12 (18%) had undergone an oxygen titration study. Overall, respiratory physicians prescriptions were more appropriate (43/74) than those issued by non-respiratory physicians (17/44; ² = 4.2, p = 0.04), and patients were more likely to be followed up (41 vs 10, ² = 12.0, p<0.001).

Conclusions: Despite restricting the prescription of home oxygen to the secondary care sector, there is a high incidence of incorrect HOOF_S and inappropriate prescription. Respiratory team are more likely to fill forms and prescribe home oxygen correctly. More formal training, especially of junior doctors may minimise inappropriate prescribing of this costly resource in the future.

PREDICTING THE DEVELOPMENT OF HYPERCAPNIA IN PATIENTS UNDERGOING LTOT ASSESSMENT
J. A. Roberts, N. Linaker, R. ODriscoll, P. M. Turkington, C. Reid, L. Mckinley, N. Diar Bakerly. Salford Royal Foundation Trust, UK

Introduction: Long-term oxygen assessment (LTOT) varies between hospitals. Two retrospective analyses suggested that a small number of patients develop acidosis after overnight oxygen (Marshall et al, 2006, Kashkhusha et al, 2006). Our current practice is to admit all patients for LTOT assessment overnight to assess the risk of hypercapnia.

Aims: To identify the subgroup of patients who would benefit from overnight oxygen assessment by retrospectively looking at their baseline characteristics.

Methods: We reviewed all LTOT assessments carried out on our patients between January 06 to July 07. Data were collected on a database then analysed. Our assessment included baseline blood gases, which were repeated after 2 h of oxygen therapy (2–4 l/min) and repeated again after overnight oxygen treatment in hospital.

Results: (1) Forty three patients were referred; 5 were excluded as found to have a satisfactory PO₂ level (>7.3) on air on the day of assessment. (2) COPD was the primary diagnosis in 97% of cases. (3) LTOT was not recommended for 7 (18%) patients due to the development of unsafe hypercapnia (PCO₂>7 kPa) and/or respiratory acidosis (PH<7.35) (5 cases on the 2-h blood gases and 2 cases on the morning blood gases after overnight oxygen). (4) The later 2 cases had baseline FEV₁ 30% and a rise of >1 kPa in PCO₂ after 2 h on 2 l/min O₂. (5) FEV₁ 30% and the rise in PaCO₂ >1 kPa after 2 h of 2 l/min O₂ had sensitivity and specificity of 100%, 59% and 100, 83% respectively for incidence of hypercapnia and/or respiratory acidosis after overnight oxygen. (6) The total number of patients, who had both of baseline FEV₁ 30% and a rise of PCO₂>1 kPa after 2 h on 2 l/min, was 5 (13%).

Conclusions: The use of overnight LTOT assessment may possibly be reserved for those patients who develop a rise in PCO₂ >1 kPa after 2 h of oxygen 2 l/min and have baseline FEV₁ 30% predicted. This would reflect the need of overnight assessment for only 13% of our patients who are referred for LTOT assessment. Further research with larger number of patients is required.

IS THERE EVIDENCE TO SUPPORT TYPE I RESPIRATORY FAILURE PATIENTS BEING ASSESSED DIFFERENTLY FOR LONG-TERM OXYGEN THERAPY ASSESSMENTS TYPE II FAILURE PATIENTS?
S. A. Kirk, S. P. Wimpress. Glenfield Hospital, UK

Introduction: Long-term oxygen therapy (LTOT) is the administration of supplemental oxygen for the treatment of respiratory failure. Guidelines for the prescription of LTOT were developed by the Royal College of Physicians in 1999. Advice such as the patients it is appropriate for, the inclusion criteria and the benefits it may have, are all clearly outlined. However the actual assessment procedure to prescribe the correct level of oxygen, required by the patient, is not stated. This audit aims to find out if the protocol used within our respiratory department can be modified for patients in Type I respiratory failure, therefore reducing the length of the test. With Type I respiratory failure, the administration of oxygen therapy ought not lead to a significant increase in their pCO₂. However patients in Type II respiratory failure, oxygen therapy may lead to worsening of their hypercapnia.

Method: The patients made two visits to the department, at least three weeks apart, at both visits blood gases by earlobe capillary sampling were measured. If on the second visit their results indicated they were still in Type I respiratory failure, they were administered oxygen at a flow rate of 2 l/min from an oxygen concentrator, for 60 min, blood gases were taken at both 30 min and at 60 min.

Results: There were 56 patients included in this audit (32 male and 24 female). The mean baseline blood gas readings were pO₂ 7.04 kPa and pCO₂ 5.48 kPa. After 30 min of oxygen mean gases were 9.37 kPa and 5.5 kPa respectively. After 60 min they showed a pO₂ of 9.55 kPa and a pCO₂ of 5.56 kPa. The baseline, 30 min and 60 min blood gases showed no significant change in pCO₂. However there was a marginal difference in pO₂ between the 30 min and 60 min. Therefore the data was re-analysed, the patients were split into two groups depending whether their baseline pO₂ was </>7 kPa. There were 27 patients in the group with pO₂ <7 kPa and 29 patients with pO₂ >7 kPa, the same statistical analysis was used. The group with a pO₂ <7 kPa again showed no significant change in pCO₂, however there was a significant difference between the pO₂ measured at 30 min and 60 min. The group with a pO₂ of >7 kPa, showed no significant difference between the pO₂ at 30 min and 60 min oxygen therapy. This suggests that in patients with a baseline pO₂ of >7 kPa, the correct level of oxygen can be determined after only 30 min of oxygen delivery.

Conclusion: We conclude that the LTOT assessment of patients in Type I respiratory failure can indeed be modified so that in patients with a pO₂ of >7 kPa the blood gas can be performed after only 30 min of oxygen delivery thereby shortening the assessment procedure which is beneficial for both patient and assessor.

Lung cancer services
THE NATIONAL LUNG CANCER AUDIT; RESULTS AND PROGRESS FOR THE SECOND YEAR, 2006
N. Chanarin¹, R. Stanley², M. Peake¹. ¹Royal College of Physicians; ²The Information Centre for Health and Social Care

Introduction: The National Lung Cancer Audit is an audit of lung cancer run jointly by the Royal College of Physicians and The Information Centre for health and social care. The audit presented its first year results (patients presenting 2005) in 2006. This abstract presents results from the second year for patients with date of first presentation in 2006. Results are compared against 2005.

Results: In June 2007 the total number of records on the database was 46 512. In 2005 77% of eligible trusts entered data, this has grown to 91% in 2006. Patient numbers have increased, 12 759 were recorded in 2005 growing to 19,887 in 2006. Of these 17 022 had a "date first seen" recorded making them suitable for analysis. In 2005 this represented 40% of the expected number of lung cancer patients in England. In 2006 this was 61%. Referral patterns are unchanged. The most common presentation remaining direct referral from GP, 49.9% of presentations. Patient journey times are similar. Time from referral to first definitive treatment 45 days in 2005, 43 days in 2006. Data completeness has improved. Items such as recording of treatment have improved considerably, however the number of records with all case mix factors completed is still low.

Conclusions: The aims for 2006 were to increase patient numbers, raise participation and improve data completeness. This has been achieved. Participation is now very high and data completeness has started to improve. This will begin to permit risk adjustment of outcomes by trust and network to be published. It is hoped that this will explain previously observed geographical variations in lung cancer outcomes.

IMPROVEMENTS IN MANAGEMENT OF LUNG CANCER PATIENTS FOLLOWING REORGANISATION OF SERVICES AT ST JAMES'S UNIVERSITY HOSPITAL, LEEDS
A. Hardy, P. Plant. St James's University Hospital, Leeds, UK

Introduction: Lung cancer services have recently been restructured with a new fast track clinic from November 2006 allowing rapid access to protected CT and bronchoscopy slots and local PET scanning since early 2007. An audit in May 2007 assessed the impact of these changes.

Methods and Results: 112 consecutive referrals to the fast track clinic were included. 40% were subsequently diagnosed with lung cancer. 45% were referred via the fast-track CO₂ form. Mean waiting from referral to clinic was 9.3 days (7.2 days for CO₂ referrals), with 90% seen within 14 days and 47% within 7 days (98% and 68% for CO₂). 76% had a CT requested from clinic. 67% of these had their CT the following day in a protected slot. Median delay from clinic to CT fell from 10 days in October 2006 to 1 day (range 1–16) in May 2007. 46% patients had a bronchoscopy requested from clinic. 77% had this on day 2 (range 1–12 days). 96% patients had CT prior to bronchoscopy compared to 0% previously. PET usage has increased from 9% to 15% patients and median delay from clinic to PET has fallen from 25 days to 10 days (range 2–51). Median time to triage for all referrals is 17 days, with 79% triaged within 31 days. 14 patients were referred to thoracic surgery and 8 of 41 (20%) lung cancer patients had a curative resection. For those referred for surgery the median triage time was 25.5 days (range 7–70) with 64% triaged within 31 days. 75% of patients had surgery within 62 days of referral. 22 of 41 (54%) lung cancer patients were referred to oncology. Median triage time was 20 days (range 11–55). 82% were triaged within 31 days and 90% received treatment within 62 days.

Conclusions: Compliance with national targets has improved. For CO₂ referrals, 98% are seen within 14 days of referral, and 91% receive treatment within 62 days. For all patients diagnosed with lung cancer, 92% received treatment within 62 days of referral compared to 34% prior to October 2006.

AN AUDIT OF USE OF CONCURRENT CHEMO-RADIOTHERAPY WITH CISPLATINUM AND VINORELBINE WITH 55 GY IN 20 FRACTIONS IN SEVEN UK TREATMENT CENTRES
V. Kelly¹, J. Hicks¹, R. Mcmenemin³, G. Skailes , C. Barnett⁵, S. Simpson⁵, J. Maguire¹, J. Maguire⁵. ¹Liverpool Lung Cancer Unit; ³Newcastle Oncology Centre; ⁴Preston Oncology Centre; ⁵Clatterbridge Centre for Oncology, UK

Introduction: We have audited treatment related toxicity in patients treated with chemo-radiotherapy in centres which had not yet opened SOCCAR.

Method: A data collection form was sent to clinicians who had treated patients with concurrent chemo-radiotherapy prior to trial entry. Information was entered onto a database and analysed using SPSS statistical software.

Results: Information was received on 85 patients treated with concurrent chemo-radiotherapy in seven radiotherapy centres. Early oesophagitis was reported in 71 patients: grade 1 in 18, grade 2 in 41 cases and grade 3 in 12. There was no grade 4 or 5 oesophagitis. Early pneumonitis was reported in 24 patients: grade 1 in 21 cases and grade 2 in 3. There was no grade 3, 4 or 5 pneumonitis. Two deaths at 78 and 84 days in one centre were attributed to aspergillosis but were associated with gross violations of the SOCCAR protocol—that is, use of neo-adjuvant chemotherapy, failure to record lung function or transfer factor, failure to use prophylactic antibiotics and treatment of an excessive v20 in one case and a major geographical miss in the other.

Conclusions: Clinicians at six radiotherapy centres have reported acceptable levels of toxicity with concurrent chemo-radiotherapy using the SOCCAR protocol. This is a safe and effective treatment, but requires careful patient selection and adherence to the protocol regimen.

ORGANISATION OF LUNG CANCER SERVICES IN MERSEYSIDE AND CHESHIRE: THE LUNG CANCER NURSES' VIEW
M. Asim, S. Durairaj, N. Sinnott, M. J. Walshaw, M. J. Ledson. The Cardiothoracic Centre-Liverpool, UK

Introduction: The lung cancer nurse specialist (LCNS) provides support and information, helping patients understand their illness. They are more in touch with patients’ views than clinician managers, and mirror their requirements from the diagnostic process. As service reorganisation to include dedicated "one stop" rapid access clinics and parallel onward referral arrangements in response to waiting time targets has caused debate within the healthcare community, we canvassed the views of LCNSs working in the Merseyside and Cheshire Lung CNG.

Methods: A 14-point questionnaire (waiting time targets, the provision of rapid access, immediate post-diagnosis and ongoing post-treatment management) was sent to all 15 LCNSs working in 7 lung cancer units (140 to >400 cases per year, 1 to 2.5 WTE LCNSs each).

Results: Of 11 (73%) anonymous replies, 8 (73%) were in favour of the 14 day, 6 (54%) of the 31 day, and 9 (82%) of the 62 day target. All indicated that patients should be seen in a dedicated clinic, and 10 (91%) that these should be "one stop" (consultation/CT scan/bronchoscopy (if indicated) on the same day). Nine (81%) thought that patients should be able to consult the relevant clinician (thoracic surgeon, oncologist, or palliative care physician) on the same day. Furthermore, 10 (91%) indicated that these specialists should sit in parallel clinics (same clinic block at the same time). All thought that nurse-led follow-up clinics were appropriate, 10 (91%) attached to a chest physician-led clinic, and all found their jobs satisfying, citing providing support and information to patients as the most rewarding part, while lack of administrative and secretarial support was the most stressful.

Conclusions: As a group, Merseyside and Cheshire CNG LCNSs support the concept of rapid access "one stop" clinics with onward referral to parallel specialist clinics, and most are comfortable with the Government waiting time targets. They support the concept of nurse-led follow-up clinics post-treatment, within the supportive environment of a physician-led clinic. Inadequate secretarial and administrative support was highlighted; inevitable problems for an important group of healthcare professionals who continue to be undervalued by healthcare management.

INCIDENCE AND DEMOGRAPHICS OF MESOTHELIOMA ON THE WIRRAL
S. Agarwal, J. A. Corless, D. Langton. Arrowe Park Hospital, UK

Introduction: The Wirral is a peninsula in the North West of England with a population of 360 000. Due to local industries such as shipbuilding rates of asbestos-related lung disease on the Wirral have traditionally been regarded as above average. We sought to investigate the incidence and demographics of new diagnosis of mesothelioma over the last six years since January 2001. Data were retrieved from the lung cancer management system.

Results: From January 2001 the total number of new cases identified was 61. Annual incidence of mesothelioma from 2001 to 2006 was 9, 7, 5, 12, 18, 9 respectively (mean = 12, median = 9). 88% (54) were males. Median age was 72 (range 51 to 90). A history of definite asbestos exposure was noted in 66% (34). 83% of cases were initially referred via the patient’s general practitioner with the remainder admitted acutely to hospital before first diagnosis. 94% had definite histological confirmation with a radiological only diagnosis in 6.5% (4). Histological typing confirmed it to be mesothelioma (unspecified) in 47, epitheloid in 8 and sarcomatous in 2 cases. The median time to reach the diagnosis was 36 days (range 6 to 264). 47 patients have now died with a median survival of 258 days (range 31–972). The addresses were plotted on the map using Microsoft Auto Route software. The majority of patients with mesothelioma live on the eastern half of the Wirral. The geographical spread closely correlates with areas of deprivation, high smoking rates and also previous high occupational users of asbestos, particularly the shipyards.

Conclusions: Our figures demonstrate burden of mesothelioma is higher than the national average. There does not however appear to be any current evidence of a rise in cases in keeping with national predictions. Cases of mesothelioma on the Wirral are higher in areas of high deprivation and smoking rates and close to previous shipbuilding activity.

ABNORMAL RESULTS OF GP-REQUESTED CHEST X RAYS COPIED TO THE HOSPITAL CHEST CLINIC: IS THERE A SIGNIFICANT DELAY BEFORE PATIENTS ARE REFERRED FROM THE COMMUNITY?
R. Bourkiza, K. Archer, B. Yung, A. Elsheikh, D. Mukherjee, J. Samuel. Department of Respiratory Medicine, Basildon University Hospitals Foundation NHS Trust, UK

Background: Many factors are responsible for the relatively poor survival rate of the UK lung cancer patients. The delay in patients being referred to the chest physicians may be a contributing factor. There are anecdotal reports of delay in patients being referred to chest clinics from primary care physicians despite having been found to have abnormal chest x rays (CXRs) suggestive of a diagnosis of lung cancer. The general practitioners (GPs) in our hospital catchment area can request CXRs to be done at our hospital and results of the CXRs are sent/faxed to the GPs. Since year 2005, any abnormal GP-requested CXR reports suggestive of the presence of lung cancer are copied to the chest clinic and GPs are advised to refer patients urgently to the chest clinic.

Aim: To establish whether patients found to have abnormal CXRs suggestive of underlying cancer (whose CXR reports were copied to the chest clinic) were referred urgently as recommended.

Method: A prospective survey covering the period of December 2006 to May 2007 was carried out. The reports of all GP-requested CXRs with abnormal results suggestive of underlying cancer copied to the chest clinic were collected. The investigators checked the hospital PAS system to establish whether the patients had been referred to the chest clinic at intervals of five working days since reports had been issued. After 15 working days, if a patient had not been referred, the GP who had requested the CXR was contacted to establish whether he/she was aware of the abnormal CXR report and whether any action had been taken. Reasons for the non-referrals were sought.

Results: During the study period, 50 abnormal CXR reports were copied to the chest clinic involving 50 patients (28 male, mean age: 70 years, range: 40–91 years). The CXRs were performed after a median of one working day (range 0–17 days) after requests were made. The reports were issued to the GPs after a median of three working days (range 0–16 days) after the CXRs were performed. The chest clinic received copies of the abnormal reports after a median of 1 working day (range: 0–8 days). Of the 50 reports returned to the GPs with recommendations of urgent referrals to the chest clinic, 48 patients (96%) were referred after a median of 1 working day (range: 0–15 days) since reports were issued. Of the 48 referrals received, 44 (92%) were referred via the 2 week wait (2WW) route. We found no significant delay in referral in the group of patients referred via the non-2WW route compared to those referred via the 2WW route. All 48 patients (including the four patients not referred via the 2WWw route) were seen within 2 weeks of referrals being received. 29 of the 48 patients (60%) were subsequently found to have cancer of which 27 patients had primary lung cancer. No referrals were received at the chest clinic for 2 patients (4%) so their GPs were contacted. We found that one patient was referred to a neighbouring hospital. One patient was a known case of bowel cancer with a new finding of lung metastasis and was referred directly to her oncologist.

Conclusion: This survey confirms that GPs receiving abnormal CXR reports responded appropriately by referring patients to the secondary care in a timely fashion. The system in place in our locality therefore appears to be working well.

A COMPARISON OF CANCER REGISTRY AND HOSPITAL-BASED LUNG CANCER CASE ACQUISITION FOR FOUR HOSPITALS IN WALES IN 2005
N. A. McAndrew¹, I. Williamson², S. Linnane³, E. Evans⁴, E. Lim1. ¹Wrexham Maelor Hospital; ²Royal Gwent Hospital; ³Cardiff and Vale NHS Trust; ⁴Swansea Hospitals NHS Trust, UK

Accurate lung cancer case registration provides the denominator for outcome comparisons in diagnosis and treatment. Wales currently uses two systems to collect lung cancer data/registrations. All hospitals use a clinical database Cancer Network Information System Cymru (CaNISC) serving MDTs, where locally inputted data are transferred to a central server. The separate cancer registry is the Welsh Cancer Intelligence and Surveillance Unit (WCISU). This audit compares case registration on WCISU (centrally) with that on CANISC (locally) for patients newly diagnosed with lung cancer in 2005. WCISU uses the following data sources: Patient Episode Database Wales (PEDW) derived from hospital codings; pathology reports from 12 out of 14 trust laboratories (histology but not cytology) and the Office of National Statistics (ONS) provides details of death certificates. WCISU does not currently use CaNISC. This audit excludes WCISU DCO (Death Certificate Only) cases—that is, those that had no second corroborating source of data.

Analysis of data from four hospitals/trusts (Newport, Swansea, Cardiff, Wrexham) found that discrepancies in the databases fell into clear groups. These included: (1) failure of MDTs to register cases that WCISU successfully recorded; (2) WCISU recording cases that were not lung cancer, with particular difficulties with "unknown primary"; (3) WCISU missing a small number of cases; (4) CaNISC cases with wrong year of diagnosis; (5) technical difficulties with WCISU "pulling through" CaNISC data.

More detailed analysis in Wrexham, Cardiff and Swansea (220 discrepant cases using case notes, pathology and radiology systems, ONS data and MDT meeting minutes) explored the reasons for the above. Cases were missed locally for two main reasons—an MDT member failing to bring the case to the MDT and cases that never had any MDT member input (these were almost all "clinical and radiological only" cases so would not be picked up by pathology surveillance). WCISU also recorded cases as lung cancer "incorrectly"—some were recorded locally as "unknown primary" and in Wrexham two cases of metastatic renal carcinoma were incorrectly recorded as "lung cancer" on the death certificate. WCISU missed four cases in Wrexham—three had no histology/cytology and two had no mention of lung cancer on the death certificate. Simple clerical errors resulted in a number of cases being put in the "wrong year". Some difficulties were found with date of diagnosis around the turn of a year. WCISU also ascribed cases to the four Trusts/hospitals that were diagnosed at other hospitals.

The audit identified several areas that can be addressed to improve accuracy and ascertainment of lung cancer data collection in Welsh Trusts and by WCISU:

This audit illustrates ways in which both registry data and local case registration can be improved. It also shows that whilst registry case registration is better it is still incomplete.

This comparison is being repeated for 2006 data but results of the 2005 audit are just being circulated and changes to practice made. The re-audit of 2007 and 2008 data will complete the cycle to see if the audit had been effective in implementing a positive change in practice.

REASONS FOR DIAGNOSTIC DELAY IN LUNG CANCER
A. S. Jackson, T. B. Ho. Frimley Park Hospital, UK

Introduction: Government targets for the diagnosis and treatment of lung cancer state that patients should receive their first treatment for lung cancer within two months from referral by the general practitioner. By 2008 the goal is to reduce this to one month. At Frimley Park Hospital, we are currently achieving the two-month target, but feel that to reduce this down to one month with the current system may be difficult. Therefore, the aim of this audit was to look at reasons for delay in diagnosing patients with lung cancer, with a view to making the system more efficient and minimising patient anxiety.

Methods: We looked at patients at Frimley Park Hospital who received their first treatment for lung cancer in the six-month period from the beginning of June to the end of November 2006. We measured the number of days from date first seen in clinic to the date of the procedure that provided the diagnosis. During this time, 12 patients out of a total of 50 had a delay in diagnosis longer than one month. Two of these were excluded, as hospital notes were unavailable. Characteristics of the patients are shown in the table. A significant number of patients had Stage IV or extensive disease and received palliative treatment.

Results: The most common reason identified for a delay in diagnosis was having to undergo more than one diagnostic procedure. Other reasons identified included admission to hospital, management outside the lung cancer multidisciplinary team, and treatment for pneumonia. In most cases the patient underwent a bronchoscopy followed by a computerised tomography (CT) guided biopsy. However, the average wait for a bronchoscopy was nine days, while the wait for a CT guided biopsy was two weeks.

Discussion: NICE guidelines recommend that CT imaging should be performed prior to undergoing a bronchoscopy. This recommendation is based on evidence from two clinical trials showing that this increases the sensitivity of bronchoscopy. In this district general hospital, patients usually attend clinic before having a CT scan, and a bronchoscopy is planned and occasionally performed before the CT scan. Patients then undergo a CT guided biopsy if the bronchoscopy does not yield a diagnosis. On retrospective review of CT imaging, CT guided biopsy or lymph node biopsy may have been the more appropriate first line investigation in six of these patients. This finding supports the recommendation that imaging should be reviewed prior to planning diagnostic procedures and we are now implementing this in our hospital. This should significantly reduce waiting time for a number of patients.

Conclusions: In summary, the most common reason for delay in diagnosis was having to undergo more than one diagnostic procedure, and these patients often had more advanced disease and were managed palliatively. Ensuring that appropriate imaging is performed prior to planning diagnostic procedures can reduce delay and lessen patient anxiety. One method of achieving this is through the introduction of early diagnosis clinics as recommended by NICE.

URGENT 2 WEEK LUNG CANCER REFERRALS FAIL TO IDENTIFY MOST PATIENTS SEEN IN SECONDARY CARE CANCER SERVICE
P. Cadden, M. Najib, E. Wilcock, K. Longmate, A. Wardman, S. Madi, I. Aziz, R. Sundar. Royal Albert Edward Infirmary, UK

Background: Lung cancer is a major cause of morbidity and mortality in the UK. Strategies to improve prognosis and access to treatment have included two-week urgent referrals. Local experience suggested to us that in the Wigan area this was not identifying most of the patients who were coming under the care of the secondary care lung cancer multidisciplinary team.

Aims: To audit the number of patients being seen and identifying areas to target to improve future access and prognosis.

Methods: A two-year retrospective audit of all lung cancer patients treated at our local district hospitals. We documented gender, age, symptoms on presentation, mode of referral, investigations performed, histological diagnosis and treatment pathway.

Results: In total 458 patients were identified for the period 1 June 2004 to 31 May 2006. 56% were male and most patients were over 65. Most patients were referred as inpatients (55%), via the Emergency department (34%) and by other consultants (21%). Routine GP referrals accounted for 12% of cases. 17% of patients were referred directly from radiology department with abnormal chest x ray appearances. Only 16% of cases were referred as urgent two week cancer referrals. Presenting symptoms included dyspnoea (39%), cough (27%), haemoptysis (14%), weight loss (19%), pain (21%), dysphonia (7%) and abnormal plain chest radiograph (81%). Over the two years 19% of patients were staged to undergo curative treatments.

Conclusions: We have implemented an abnormal chest x ray meeting so all abnormal plain chest x rays are discussed and prioritised each week. It is not beneficial for patients to have to wait for symptoms to progress to a point where they need to have an unscheduled healthcare episode. In view of the high number of patients self-presenting to the hospital in our area we are putting in place an awareness program for local patients and GPs to emphasise the importance of plain chest x rays and early referral in identifying patients with lung carcinoma. We feel that in those patients that present with chest symptoms and are current or significant ex-smokers an early chest x ray is indicated.

AUDIT OF LUNG CANCER WAITING TIMES AT A DISTRICT GENERAL HOSPITAL
K. Mortimer, S. Mallawathantri, A. Rousell, N. Ali, G. Cox. King's Mill Hospital, UK

Background: The Department of Health Cancer Waiting Time (CWT) targets specify a maximum 62-day wait from urgent (two-week wait) GP referral for suspected cancer to first definitive treatment and a maximum 31-day wait from diagnosis (decision to treat) to first definitive treatment. Waiting Time Adjustments (WTAs) are allowed for certain circumstances that are out of the control of the NHS.

Methods: We undertook an audit of all urgent GP referrals with a final diagnosis of lung cancer in 2005 and 2006 to determine: (a) the extent to which CWT targets were met; (b) the reasons for missing CWT targets; (c) the effects of and reasons for WTA; (d) the time between the decision to provide a specific treatment and implementation of treatment.

Results: The main reason for missing CWT targets was the need for multiple tests to make a diagnosis in more complex cases while the main reasons for WTA were patient fitness, patients needing time to think and missed appointments.

Conclusions: Average waiting times were within the CWT targets and were shorter in 2006 than in 2005 probably reflecting the appointment of a full time cancer tracker and MDT coordinator, the use of the live Orion tracker system and the development of a local PET service. CWT targets were missed mainly due to difficulties establishing a diagnosis in more complex cases. WTA has little effect on time from referral to treatment. Treatment is provided promptly following the decision to treat.

WHAT HAPPENS TO LUNG CANCER PATIENTS AFTER TREATMENT? AUDIT AT 4 YEARS
A. McIver, M. Ellison, H. Bonwick, J. Hughes, V. Kelly, M. J. Walshaw. The Cardiothoracic Centre-Liverpool, UK

Introduction: Although the lung cancer diagnostic and treatment pathway is streamlined, there is little research on the subsequent patient journey which ends in death for the vast majority. We looked at this aspect in our large lung cancer unit.

Methods: Outcome of diagnoses within our catchment area in 2003 was audited. Entries from the Cancer Registry and our database were searched to ensure a complete denominator: treatment, survival, and place of death data were collected yearly until 2007 (4 years).

Results: There were 354 cases (199 male (59%)): 197 (58%) non-small cell, 53 (15%) small cell, and 104 (29%) clinical diagnosis. Mean diagnostic time was 28 days (median 16). At diagnosis, PS = 0 in 50 (14%), = 1 in 106 (30%), = 2 in 90 (25%), = 3 in 51 (15%), = 4 in 3 (1%), and 54 (15%) were not recorded. 29 (8.2%) underwent curative surgery alone, 5 (1.4%) surgery with adjuvant oncology, 234 (66.1%) oncological treatment (of which 70 had specialist palliative care (SPC) input), 34 (9.6%) SPC alone, and 52 (11.1%) were not recorded. For survival data see table. Of the 316 deceased, 159 (50%) died at home, 118 (37%) in hospital and 39 (12%) in a hospice. Of these groups, 36%, 28%, and 28% respectively had SPC input at diagnosis.

Conclusions: Survival in the surgical and oncological groups was respectable, with >50% undergoing attempted curative resection alive at 4 years. The low resection rate (9.6%) reflects our inner city catchment area, with high comorbidity and late presentation. Despite this, the majority of patients died at home, out of keeping with national figures: this may reflect the supportive services model we have adopted as part of our MDT approach. Further attention should be paid to the "downstream" part of the lung cancer patient journey, which is of increasing duration for the majority of patients.

GLOBAL PALLIATIVE CARE NEEDS IN LUNG CANCER PATIENTS ARE ASSOCIATED WITH PRESENCE AND SEVERITY OF RESPIRATORY SYMPTOMS BUT NOT INFLAMMATORY RESPONSE OR ALBUMIN LEVEL
D. Buchanan1, A. Thompson¹, R. Milroy², P. Levack³. ¹University of Dundee; ²Stobhill Hospital; ³NHS Tayside, UK

Introduction: Lung cancer is the commonest cause of cancer related deaths in Scotland, the UK and worldwide. It is a disease of high symptom burden, psychosocial effects and poor prognosis. Palliative care has an increasing role in multidisciplinary lung cancer management. The palliative outcome scale (POS) has been developed and validated in several clinical settings as a tool to identify and quantify palliative needs. Elevated C-reactive protein (CRP) and reduced albumin are associated with shorter survival. This study compared respiratory symptoms, POS, CRP and albumin in lung cancer patients attending an out-patient clinic.

Methods: 115 patients attending a lung cancer clinic completed a questionnaire containing the POS and three questions rating the severity of dyspnoea, cough and haemoptysis. CRP and albumin of each patient at diagnosis was measured.

Results: The presence and severity of dyspnoea, cough and haemoptysis were associated with increased palliative needs as measured by POS. (POS 0–4 vs 5–9, p = 0.002, POS 5–9 vs 10–14, p<0.001, POS 10–14 vs 15+, p = 0.042). Albumin and CRP were not associated with POS.

Conclusion: Raised CRP and low albumin are known adverse prognostic factors in lung cancer but do not predict overall palliative care needs as measured by POS. The symptoms of dyspnoea, cough and haemoptysis in lung cancer out-patients are associated with their palliative needs. These results emphasise the importance of identifying the presence and severity of physical symptoms. This simple approach may allow early identification of patients who are likely to benefit from specialist palliative care services irrespective of their individual prognosis.

Improving outcomes in lung infection
STATIN USE REDUCES MARKERS OF SYSTEMIC INFLAMMATION AND 30-DAY MORTALITY IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA
J. Chalmers, A. Singanayagam, A. Hill. Royal Infirmary of Edinburgh, UK

Introduction: Previous retrospective studies have shown a reduced incidence of community acquired pneumonia (CAP) and improved outcomes in patients taking HMG co-A reductase inhibitors (statins), thought to result from anti-inflammatory effects. We tested the hypothesis that markers of systemic inflammation would be lower in patients with CAP taking statin therapy and that this would be associated with superior outcomes.

Methods: We performed a retrospective study of 514 patients over the age of 50 with a diagnosis of CAP between February 2005 and February 2007. C-reactive protein and fibrinogen were measured on admission as markers of systemic inflammation. The outcomes of interest were: admission CRP and fibrinogen; need for mechanical ventilation and/or inotropic support; development of complicated pneumonia (lung abscess, empyema or complicated parapneumonic effusion); 30-day mortality. Multivariate logistic regression was performed adjusting for age, sex, comorbidity, smoking status and pneumonia severity.

Results: Data are presented as median interquartile range (IQR). Patients receiving statins were significantly older 74 years (61–81) vs 70 (61–79), p<0.01, more were male (53% vs 46%, p<0.01), more had chronic cardiac disease (28.4% vs 11.6%, p<0.0001) or stroke (15.4% vs 9.7%, p = 0.05). The severity of pneumonia using CURB65 score was not significantly different between groups- 2 (2–3) on statins vs 2 (1–3) not on statins. C-reactive protein and fibrinogen levels were significantly lower in patients receiving statin therapy (see table). There was no significant difference in rates of complicated pneumonia (1.8% on statins vs 5.9%) or requirement for invasive ventilation and/or inotropic support between groups (10.5% on statins vs 12.8%). On multivariate analysis there was a reduction in 30-day mortality in patients receiving statin therapy (11.7% on statins vs 16.8%, OR 0.48 (0.25–0.90), p = 0.02).

Conclusion: Markers of systemic inflammation and 30-day mortality are reduced in patients with CAP treated with statins.

DOES DOCUMENTING THE CURB-65 SCORE IMPROVE APPROPRIATE INITIAL EMPIRICAL ANTIBIOTIC THERAPY IN THE MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA?
O. J. Eneje¹, A. Colville³, B. D. Patel². ¹Royal Devon & Exeter Foundation Trust; ²Department of Respiratory Medicine, Royal Devon & Exeter Foundation Trust; ³Department of Microbiology, Royal Devon & Exeter Foundation Trust

Introduction: The BTS recommend the use of the CURB-65 to identify patients at risk of a poor prognostic outcome from community-acquired pneumonia (CAP) and to guide appropriate choice of antibiotic therapy. We assessed if the CURB-65 system was being effectively used to guide appropriate antibiotics prescription in patients admitted with CAP to our hospital.

Method: Retrospective case note and drug chart review of all patients admitted with CAP to the emergency medical unit during December 2006. Data obtained included demographics, previous antibiotic therapy, baseline observations, investigation results and documentation of the CURB-65 on admission. If the CURB-65 was not documented it was calculated making the assumption that, unless otherwise stated, the patient was not confused.

Results: Forty eligible cases (57.5% male) were identified, median age 76.0 (IQR 25) years. Admission CURB-65 was documented in 10 cases, only one patient had a documented mini-mental test. CURB-65 scores were calculated for the remaining 30 individuals. Twenty-one (52.5%) patients were started on appropriate antibiotics according to documented or estimated CURB-65 score, this increased to 32 (80%) following consultant review. In only two cases was it documented why an alternative antibiotic was used. 70% of patients with a documented CURB-65 on admission received appropriate antibiotics, compared with 46.7% of those in who the CURB-65 was not documented (p = 0.2, ²). Ten patients had severe CAP (CURB-65 >2), but in only 4 was the CURB-65 documented on admission and 3 of these received appropriate antibiotics. Of the remaining 6 patients, only 2 were initiated on appropriate therapy. The overall mortality was 15%, of which 2 had a documented or estimated CURB-65 >2 on admission.

Discussion: The overall rate of conformity to hospital guidelines for the initial management of CAP was low (52.5%), but increased to 80% following consultant review. Documentation of the CURB-65 score on admission improved compliance with the guidelines (not statistically significant). Only two cases had a documented clinical justification for deviation from antibiotic guidelines. An increase in use of the CURB-65 by junior medical staff may increase concordance with antibiotic policy in the treatment of CAP.

IS TIMING OF INITIAL ANTIBIOTIC ADMINISTRATION RELATED TO OUTCOME IN COMMUNITY-ACQUIRED PNEUMONIA?
S. E. Hill, M. Woodhead. Manchester Royal Infirmary, Manchester, UK

Introduction: Common sense suggests that delays in antibiotic administration in infections may be associated with worse outcome. There is some research evidence to support this in CAP which has lead to all National and International Guidelines making a recommendation about the importance of early antibiotic administration.

Aims: To examine time of antibiotic administration in relation to outcome in adult patients with CAP.

Methods: This was a retrospective case control study. Cases coded as ICD10 J10-J18 were identified from the Hospital Information database for 1 January 31 December 2006 and case records examined. Cases were excluded if notes were not available, if the diagnosis was wrongly coded, if significant information was missing, if immunocompromised, nosocomial infection or if considered to be a terminal event. Data were extracted manually and recorded in an Excel spreadsheet and analysed using parametric and non-parametric statistical tests.

Results: 489 cases were found of which 129 (27%) had died. All 129 dead notes were sought and 54 included in the analysis (37 not found and 38 excluded for above reasons). One in three live notes were sought and 150 of 266 examined were included (53 not found and 63 excluded for above reasons). Patients that died were older (median age 81 vs 65, p = 0.7; and were significantly more likely to be in CURB-65 group 3 (score 3–5) (54% vs 12%) than Group 1 (0–1) (15% vs 57%) p<0.001. There was no difference in the median time to first antibiotic administration between dead (3 h 29) and live (3 h 24) patients p = 0.7, but a significantly greater proportion of those who died only received first antibiotics after 8 hours (20% vs 8%). In a previous audit prior to the introduction of the 4-h A&E waiting rule, 22% of patients only received antibiotics after 8 h suggesting that speed of antibiotic administration had improved (p = 0.06). Factors significantly related to delay in first antibiotic prescription included lower CURB-65 score, p<0.0001, (CURB-65 1 3 hrs56, CURB-65 2 3 h 38, CURB 3 2 h 53), IV vs PO (p<0.0001), A&E prescription vs MAU (p<0.0001) and time of arrival (p<0.0001). Those arriving between 21:00 and 09:00 had a longer delay before first antibiotic. CURB-65 score was only recorded in 15% of those that died and 20% of the living and in 18% of these it was recorded incorrectly (usually incorrectly high).

Conclusions: Time to delivery of first antibiotic to patients with CAP appears to have improved, but a worrying proportion still only receive first antibiotics after 8 h from admission. This might be improved by more rigorous use of CURB-65 scoring, and first administration before patients leave the emergency department.

ARE WE PRESCRIBING TOO MANY ANTIBIOTICS FOR ACUTE HOSPITAL ADMISSIONS WITH COMMUNITY ACQUIRED PNEUMONIA?
A. Choudhury, S. Fong, S. Saha, W. Ahmed, C. Brook, T. Fernandez, L. Kuitert.Royal London Hospital, Barts and The London NHS Trust, UK

Introduction: British Thoracic Society (BTS) guidelines recommend the use of severity assessment scoring to guide management and choice of antibiotics for community acquired pneumonia (CAP) (Thorax 2001;Suppl 4:S56). The guidelines suggest there may be a trend towards over-prescribing of antibiotics in CAP.

Aim: To determine appropriateness of antibiotic prescribing for CAP.

Methods: We carried out a prospective audit for 8 weeks beginning January 2007 on patients given antibiotics for suspected CAP that required hospital admission. Data were collected from medical records at time of post-take ward round. Only patients with clear consolidation on plain chest x ray were included. CAP severity was assessed using the 5-point CURB65 score. (C: Increased Confusion, U: Urea>7.0, R: Respiratory rate>30, B: BP systolic<90, 65: Age >65 years). The score would be calculated by the auditing doctor if not recorded by the admitting doctor. Management by acute medicine, respiratory and non-respiratory teams at time of post-take ward round was compared.

Results: Sixty four patients (median age 74 years, males 37 (58%)) were admitted with CAP. Only 6/64 (9%) of cases had a CURB-65 severity score recorded by the admitting doctor. Parenteral administration and the use of two concomitant antibiotics were common in patients with low CURB-65 scores. Despite the BTS guidelines, cephalosporins were regularly prescribed in patients with severe pneumonia (CURB-65 >2). Respiratory teams were less likely than medical teams to prescribe intravenous antibiotics in patients with CURB-65 <3 and more likely to in the severe group (CURB-65 >2); similarly they prescribed much fewer cephalosporins.

Conclusions: In our hospital, failure to implement severity scoring for CAP resulted in over-prescription and inappropriate selection of antibiotics in non-severe patients. Respiratory teams followed the guidelines more closely than general medical teams. More education for both respiratory and non-respiratory specialists is needed to ensure severity scoring and appropriate management thereafter becomes routine practice for CAP.

MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA: APPROPRIATE USE OF SEVERITY ASSESSMENT TOOL
V. S. Sreeguru Lakshman, M. Asim, M. Mcgovern, P. Stockton. Whiston Hospital, UK

Introduction: CAP is associated with significant mortality, morbidity, and burden on health care resources. British Thoracic Society (BTS) published guidelines for the management of CAP in 2001 (updated in 2004).

Aim: Establish whether we were following the BTS guidelines and using a validated assessment tool—that is, the CURB-65 score.

Method: Retrospective study. Patients admitted (April 2005–April 2006) with a confirmed diagnosis of CAP identified from the hospital database. Data collected using a modified BTS CAP audit tool.

Results: Fifty patients. Mean age 60 years (16–94). 16 (32%) were males and 34 were (68%) females. Mean length of stay was 14 days (1–63 days). 29 (58%) had significant co-morbidities. 33 (66%) current/former smokers, 13 (26%) non-smokers, 4 (8%) no smoking history recorded. CURB-65 score was documented in only 7 (14%). We retrospectively calculated the score for the remainder from data available in the medical records. 15 (30%) had a score of 0; 14 (28%) had a score of 1; 9 (18%) had a score of 2; 11 (22%) had a score of 3; 1 (2%) had a score of 4 and no patient had a score of 5. 72% had arterial blood gases done and 58% were found to be hypoxic (PaO₂ <10). 45 (90%) had senior review (SpR/Consultant) within 24 h, 3 (6%) within 2 days and 2 (4%) within 3 days. 34 (68%) had follow-up appointment. 12/33 (36%) of smokers (current and former), who would be considered high risk for underlying cancer, had no follow-up arrangements made.

Conclusions: Improvements are required in the severity assessments and the documentation of the CURB-65 score at the time of admission. Over 50% of patients had a CURB-65 score of 1, and could have been managed in the community. Over one third of smokers (high risk for underlying cancer) did not undergo a follow up chest x ray and assessment. We have introduced guidelines to facilitate appropriate evidence-based management of CAP within our Trust. We are promoting awareness regarding our pre-existing post-pneumonia clinic and use an x ray coding system to highlight abnormal x rays.

SEVERITY ASSESSMENT AND ADHERENCE TO TREATMENT GUIDELINES HAS POSITIVE IMPACT ON TREATMENT OUTCOME IN HOSPITALISED COMMUNITY-ACQUIRED PNEUMONIA PATIENTS
V. Dudzevicius, N. Krishnaraj, G. Antunes, S. A. Murphy. The James Cook University Hospital, UK

Aim: To evaluate the rates of assessment of community-acquired pneumonia (CAP) severity and impact of adherence to the BTS guidelines on the outcome.

Materials and Methods: Retrospective study was done in 90 cases of patients hospitalised with diagnosis of pneumonia. 20 patients were excluded because of other diagnoses. 70 cases were eligible for further analysis. CURB-65 score assessment on admission and treatment according to BTS guidelines were analysed. Impact of CURB-65 score, antibacterial treatment route and length on mortality and relapse or readmission was analysed by means of logistic regression. Statistical analysis was done using SPSS software.

Results: CURB-65 score was recorded in 13.2% (n = 9) of all patients: 26% (n = 6) of patients admitted to Respiratory Medicine ward; 6.3% (n = 1), Medical Assessment Unit; 15% (2), other medical wards; and 0%, Elderly Care/surgical/ITU wards. Treatment guidelines were fully or partially met in 93.8% (n = 61) of patients. Hospital mortality rate was 12.3%. There were no deaths in patients with CURB-65 score less than 2 points (p<0.05). Mortality rates were 25% and 11.5% in non-compliant vs fully/partially compliant with BTS guidelines treatment group (p>0.05). Higher rates of relapse/readmission were found in noncompliant vs. compliant with BTS (100% vs 20.4%, p<0.05) or given oral vs intravenous antibiotics on admission (32.1% vs 17.2%, p<0.05) groups. Increasing CURB-65 score was positively (OR 2.89; CI 1.21 to 6.89, p = 0.017) and antibacterial treatment duration was negatively (OR 0.73; CI 0.56 to 0.96, p = 0.025) related to in-hospital mortality.

Conclusions: CURB score was assessed in minority of CAP patients admitted to hospital, especially admitted to other than Respiratory wards. Mortality was significantly related to increasing CURB-65 score points. Relapse or readmission was more frequent in patients not treated according BTS guidelines and not given intravenous antibiotics on admission.

DO SPIROMETRY, COUGH AND PATIENT PERCEIVED SYMPTOMS CHANGE FOLLOWING INTRAVENOUS ANTIBIOTICS FOR AN ACUTE EXACERBATION OF BRONCHIECTASIS?
O. Hewitt¹, J. M. Bradley², J. Ferguson³, S. E. Elborn1. ¹Regional Respiratory Centre, Belfast Trust, Belfast City Hospital; ²University of Ulster; Regional Respiratory Centre, Belfast Trust, Belfast, City Hospital; ³Regional Respiratory Centre, Belfast Trust, Belfast City Hospital, UK

Introduction: Bronchiectasis results in increased frequency of exacerbations often requiring intravenous (IV) antibiotics. During an exacerbation, patients experience worsening of symptoms and spirometry which subsequently improve following IV antibiotics. These outcomes are frequently used to assess individual patients’ response to treatment.

Aims: To assess changes in spirometry, cough and symptoms following IV antibiotics; a secondary objective was to establish if there was a relation between change in spirometry and change in cough and symptoms.

Methods: From January to May 2007 all patients attending a specialist bronchiectasis service with an acute exacerbation of bronchiectasis (O’Donnell et al) requiring IV antibiotics completed spirometry, the Leicester cough questionnaire and were asked questions relating to four key bronchiectasis symptoms (quality of life, sputum clearance, change in symptoms and overall tiredness). Patients were assessed at the beginning and end of IV therapy. The Leicester cough questionnaire contains three domains, domain scores range from 1–7 (higher scores indicate less severity); bronchiectasis symptoms domain scores range from 1–5 (higher scores indicate severity).

Results: Data from 50 patients mean (SD) 59 (10) years were analysed. The mean baseline FEV₁ % 52 (26)%. There was a significant improvement in FEV₁ following IV antibiotics 3.5 (9.5)% p = 0.01. There was a significant improvement in the Leicester questionnaire domain scores following IV antibiotics: physical, 0.63 (0.97); psychological, 0.86 (1.29); and social, 0.74 (1.29). There was a significant improvement in three of the four key bronchiectasis symptoms following IV antibiotics: quality of life 0.64 (1.63), symptoms 0.77 (1.40), and tiredness 0.70 (1.24). There was no relation between change in lung function and change in cough or symptoms.

Conclusion: Individual changes in spirometry following IV therapy are small. Improvements in cough and other symptoms related to bronchiectasis are not captured by changes in spirometry. Inclusion of cough and symptoms scores in assessing outcome of treatment and response to IV antibiotics may be valuable in capturing the benefit of treatment more fully.

OUTCOMES OF EXACERBATIONS OF NON-CYSTIC FIBROSIS BRONCHIECTASIS MANAGED WITH TWO WEEKS' INTRAVENOUS ANTIBIOTIC THERAPY
M. Murray, A. Hill. Royal Infirmary of Edinburgh, Edinburgh, UK

Aims: The aim of the study was to assess the efficacy of two weeks’ intravenous antibiotic therapy in patients with non cystic fibrosis bronchiectasis presenting with an exacerbation. Endpoints were sputum microbiology, 24-h sputum volume, FEV₁, FVC, distance achieved in the incremental shuttle walk test and cough severity as measured by the Leicester Cough Questionnaire (LCQ).

Methods: Patients presenting with an exacerbation of bronchiectasis between January 2007–June 2007 and received two weeks’ antibiotic therapy were assessed. The antibiotic therapy given was based on current or, if necessary, previous sputum microbiology and all patients received 14 days of antibiotics. At baseline (within 24 h of starting antibiotics) and at the end of antibiotic therapy (day 14) patients had spirometry, shuttle walk test, 24-h sputum collection, sputum sent for microbiological culture and completed the LCQ.

Results: Fifteen patients were treated. The mean (SD) age was 67 (11) years. 80% had pathogens in their sputum at the start of the exacerbation. Sputum bacteriology included Pseudomonas aeruginosa (PA) 46.6%, Haemophilus influenza, Staphylococcus aureus, Moraxella catarrhalis, Escherichia coli and Serratia species 6.7% respectively. Patients with PA received two antibiotics (Ceftazidime and Gentamicin). All other patients received a single antibiotic according to organism sensitivities. Following two weeks’ antibiotic therapy, eradication was achieved in 66.7%, with no significant pathogens identified in the sputum (p<0.005). 13.3% were no longer expectorating sputum. The remaining 20% continued to have the same pathogens isolated from the sputum- in all cases PA. The effects on 24-h sputum volume, FEV₁, FVC, incremental shuttle walk test and the LCQ is shown in the table.

Conclusions: Two weeks of intravenous antibiotic therapy in exacerbations of non cystic fibrosis bronchiectasis led to significant sputum bacterial clearance. Despite no improvement in spirometry, there was a reduction in 24-h sputum volume, an improvement in exercise capacity and a reduction in cough severity.

MEASUREMENT OF TREM-1 IN EXACERBATIONS OF BRONCHIECTASIS
R. Siva, W. Monteiro, C. Payne, D. Parker, I. D. Pavord, S. P. Range, C. E. Brightling. Institute for Lung Health, Glenfield Hospital, UK

Introduction: TREM-1 is a glcoprotein expressed on monocytes, macrophages and neutrophils. Its expression is increased on exposure to extracellular bacteria. Raised TREM-1 has been shown to be a predictive biomarker for pneumonia and we have previously measured TREM-1 during exacerbations of COPD. In this study we aimed to investigate the relationship between TREM-1 and markers of bacterial infection and airway inflammation in patients with an exacerbation of bronchiectasis, both before and after antibiotic therapy.

Method: We recruited 17 patients mean (range) age 58 (40–75) with HRCT confirmed bronchiectasis. 11 patients had never smoked, 5 were ex-smokers, 1 currently smoked. On admission we measured spirometry, temperature, WCC, CRP, and symptom score using visual analogue scales. Spontaneous sputum was obtained for culture and we measured sputum colour score, differential cell count, bacterial load, and TREM-1 using an ELISA. These measurements were repeated after 10 days of intravenous antibiotic therapy.

Results: Overall mean bacterial load fell from 3.0x10⁷ cfu/ml to 2.9x10⁶ cfu/ml, p = 0.004. Sputum neutrophil % decreased by 18.5 (95% CI 3.5 to 33.4, p = 0.019). CRP improved by 15.3 (95% CI 0.1 to 30.6, p = 0.049. Symptom score improved from 203.9 to 141.8, mean difference 62.1 (95% CI 25.6 to 98.7, p = 0.003). There was no statistical difference in change in sputum colour score, WCC, or FEV1. Overall TREM-1 increased by 1036.7 pg/ml (95% CI 945.6 to 2999.1, p = 0.28). There was a trend towards an association between change in TREM-1 and change in sputum neutrophil % (r = –0.53, p = 0.061).

Conclusions: There was no significant association between change in TREM-1 and change in bacterial load or neutrophilic airway inflammation during exacerbations of bronchiectasis. The role of TREM-1 as a biomarker for bacterial infection needs further investigation.

THE BURDEN OF LUNG DISEASE IN A COHORT OF PATIENTS WITH PRIMARY ANTIBODY DEFICIENCY ON LONG-TERM IMMUNOGLOBULIN REPLACEMENT
W. N. Lee¹, M. J. Thomas², M. Brownlie², E. Ross¹. ¹Department of Respiratory Medicine, Gartnavel General Hospital; ²Department of Immunology, Western Infirmary

Background: Antibody deficiency is a rare cause of recurrent or severe respiratory tract infections. Some patients have persistent respiratory symptoms despite optimal immunoglobulin replacement. We therefore established a joint immunology/respiratory clinic to assess patients receiving immunoglobulin replacement therapy.

Aim: To evaluate the prevalence and pattern of lung disease in our cohort of patients with primary antibody deficiency on long-term immunoglobulin replacement.

Design: A retrospective analysis of clinical data was performed.

Results: Detailed clinical information was available for 48 patients: Common variable immune deficiency (34/48), X-linked