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An overview of some of the key topics presented at the BTS Winter Meeting held in London in December 2005
The annual winter British Thoracic Society (BTS) meeting held in London on 7–9 December 2005 combined a fascinating retrospective of past achievements in respiratory medicine while looking forward to the challenges that lie ahead. The meeting provided, as usual, a vital platform for clinicians to share best practice and to keep abreast of the rapidly advancing speciality. A highlight was the celebration of the 20th anniversary of British Lung Foundation, with a review of the major advances in respiratory medical research made in recent years.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
The priority given to chronic obstructive pulmonary disease (COPD) at this meeting reflected both the clinical burden of disease and the current interest in terms of clinical and basic research in this field. In a lively “pro-con” debate, some of the more controversial issues in disease management were addressed. Arguments included the new BTS President Professor Peter Calverley’s persuasive case that COPD was indeed a useful diagnostic term, as well as lively debate on the evidence for the use of inhaled corticosteroids. With the radical reforms to the provision of home oxygen imminent, a number of sessions concentrated on the new service and the potential impact on patients and providers alike. A presentation highlighted the increase in service provision required to support home oxygen assessments,1 while posters highlighted the benefits of developing a register of COPD patients suitable for long term oxygen therapy (LTOT)2 and the efficacy of ambulatory oxygen in pulmonary rehabilitation.3
The pathogenesis of airways obstruction and exacerbations were the focus for presentations on the role of infection and inflammation in COPD. Highlighting the recent advances in our understanding of this condition, presentations ranged from the findings of a study of antibiotic therapy which reduced airway inflammation,4 evidence for the role of respiratory syncytial virus (RSV) in airway inflammation and disease progression in stable COPD,5 to description of in vitro models of the airway for studying innate immune responses.6 Current thinking on the provision of services for COPD patients was addressed on the final day, underlining the role multidisciplinary community based teams may play in reducing hospital admissions and improving outcomes.7
PULMONARY REHABILITATION
The posters on pulmonary rehabilitation provided useful insights into developments in the application of this treatment. Reassuringly, two studies8,9 indicated that obese patients with COPD do benefit from pulmonary rehabilitation, while admission to hospital for exacerbations can be reduced in severe disease by physiotherapy led community disease management.10
Findings were presented suggesting that occupational therapy focusing on activity management improves both health status11 and patient satisfaction.12 While anxiety and depression were identified as risk factors for failure to complete rehabilitation,13,14 targeted interventions such as anxiety management may improve outcomes in this area.15
ASTHMA
One of the meeting’s first sessions highlighted the continued advances made by UK researchers in the understanding of airway inflammation in asthma. Work on the inflammatory profile of a phenotype of steroid resistant non-eosinophilic asthma was presented,16 and the deleterious pro-inflammatory effects of inhaled pollutants were described using a novel 2 hour “real life” exposure on London’s Oxford Street.
The epidemiology of asthma continues to be an active area of research; a spoken session cast light on the pathogenesis of thunderstorm outbreaks of asthma,17 and the use of cluster analysis models to identify and predict prognosis in distinct asthma phenotypes.18 An optimistic tone was set by the session on “Looking towards new treatments for asthma” with presentations on the possible future role of targeted anti-cytokine and anti-IgE therapy.
BASIC SCIENCE
Collaboration between the British Association for Lung Research (BALR) and the BTS produced a day long symposium focusing on the current state of the art in stem cell research and the possible future therapeutic indications and benefits in respiratory disease. Another symposium in the area of basic science covered work on the genetics of airways disease, and there were several presentations concentrating on mechanisms common to a number of lung diseases. This included work on the mechanisms of differentiation of fibroblasts to myofibroblasts,19 the role of glutathione S-transferase P1 (GSTP1) polymorphisms in controlling lung development and repair,20 and the encouraging work on the role that retinoid therapy may play in alveolar repair.21
OCCUPATIONAL LUNG DISEASE
The symposium on occupational lung disease informed on how the Health and Safety Executive targets on reducing work related ill health will be met, suggested a model for providing excellence in service, and discussed limitations and practical approaches to the diagnosis of occupational lung diseases. The problem of under-diagnosis and under-reporting of occupational asthma was highlighted following a pilot surveillance scheme in Scotland,22 with concerns about variability in diagnostic standards revealing the need for better training.23
RESPIRATORY MUSCLES AND NIV
Important developments in physiological assessment of respiratory diseases, with focus on the use of magnetic nerve stimulation and oesophageal electromyography were presented. The Moran Campbell Lecture was introduced by Professor John Gibson who gave an insight into the enthusiasm of the late Dr Campbell and reviewed his seminal work on the mechanics of breathing, sensation of dyspnoea, and the safe administration of oxygen therapy. This was followed by Dr Michael Polkey’s lecture on neuromuscular limitations in health and disease in which he explained the clinical relevance of cortical drive and muscle fatigue, and alluded to earlier spoken sessions on quadriceps muscle contractility24 and endurance.25
SLEEP DISORDERED BREATHING AND OBSTRUCTIVE SLEEP APNOEA
The increasingly recognised clinical problem of obstructive sleep apnoea (OSA) was highlighted in a number of sessions. One study showed that the need for continuous positive airway pressure (CPAP) therapy cannot be predicted reliably by a clinical questionnaire for patients referred from primary care.26 Other work described the effects of CPAP on attenuation of the cardiovascular response to arousal27 and improving vasomotor tone,28 and hence a role for this treatment in reducing cardiovascular risk in this patient group. Another study attributed the increase in cardiovascular mortality seen in OSA to findings of impaired cardiac metabolism and dysfunction.29
ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)
Presentations demonstrating advances in the understanding of the basic pathological mechanisms of ARDS from both in vitro and murine models explained the mechanism of stretch induced lung injury through the ERK1/2 pathway,30,31 and the importance of TNF receptor 1 signalling in stretch induced pulmonary inflammation.32 A potential role for vascular endothelial growth factor (VEGF) in the regenerative phase of ARDS was suggested by a presentation of its activity on primary lung epithelial cells.33
PULMONARY EMBOLISM AND PULMONARY HYPERTENSION
Presentation of audits on the diagnosis of pulmonary embolism (PE) suggested that the BTS guidelines may be poorly implemented in the absence of local agreements within hospitals.34–37 Early discharge following anticoagulation was shown to be safe for selected patients diagnosed with PE,38 and a prospective 1 year randomised study of 3 or 6 months’ anticoagulation for uncomplicated PE showed no difference in recurrence, deaths, or major haemorrhage.39 However, another study suggested that secondary pulmonary hypertension is a common problem even after 6 months’ anticoagulation and deserves further consideration.40
A comprehensive symposium on pulmonary arterial hypertension covered the spectrum of pathogenic causes for this condition, stressed the importance of molecular genetics, suggested novel therapies targeting multiple pathogenic pathways, and finally discussed the role of biomarkers and monitoring of outcomes.
MALIGNANT DISEASE
Lung cancer and mesothelioma were discussed in two well attended symposia. The first session was a multidisciplinary presentation addressing issues such as optimum services for investigation of patients with suspected lung cancer, information given to patients during the diagnostic pathway, the crucial role of the lung cancer specialist nurse, and the role of palliative chemotherapy in patients with poor performance status. The second symposium reminded us of the rising incidence of mesothelioma and highlighted the key differences in the relationships between asbestos exposure and lung cancer and asbestos exposure and mesothelioma.
The yield of bronchoscopy for detecting lung cancer in smokers and ex-smokers aged over 50 presenting solely with pneumonia was presented,41 and the usefulness of targeted bronchial cytology in lung cancer patients with normal bronchoscopic findings was presented by another group.42 The benefits of implementing a “safety net” protocol and a coded radiographic reporting system for all chest radiographs were also presented.43,44 Several reports on changes in the organisation of lung cancer services described increases in the total number of CT scans, in the number of CT scans performed before bronchoscopy, and in the number of CT guided biopsies, with a parallel decline in the number of fibreoptic bronchoscopies.45–48 The surgical experience of patients deemed unfit for surgery according to the BTS guidelines,49 as well as in patients with stage III non-small cell lung cancer undergoing surgical resection after neoadjuvant chemotherapy, was reviewed.50
PLEURAL DISEASE
A session on pleural infection included a randomised trial comparing intrapleural urokinase with video assisted thoracoscopic surgery for the treatment of empyema in children,51 and data from the MRC/BTS MIST1 trial cohort on the survival significance of different bacterial classes in pleural infection.52 The finding that management of spontaneous pneumothorax in well selected patients could be safely achieved with the use of a thoracic vent device may alter practice.53 The clinical usefulness of ultrasound in the detection of malignant pleural disease with a pleural effusion was presented,54 and the role of “blind” trucut pleural biopsy in the investigation of pleural effusion was also described.55
CYSTIC FIBROSIS (CF)
A debate on the best way to diagnose CF related diabetes followed data on the long term effects of diabetes and insulin treatment on clinical status and lung function.56 The effects of air pollutants and seasonality on CF exacerbations57 and a national survey on the management of CF exacerbations by paediatric and adult CF physicians were also presented.58 The issue of systemic and airway inflammation in stable state and at exacerbations of CF was addressed in several posters,59–62 and the difficult issue of palliative care in CF was addressed in an interesting session.63
PULMONARY INFECTION
Pulmonary infection held a prominent place again at the BTS winter meeting with symposia on tuberculosis (TB) and respiratory viruses as well as several spoken and poster discussion sessions.
Professor Stewart Cole delivered a fascinating Snell memorial lecture on the genomics of Mycobacterium tuberculosis. Spoken sessions on TB varied from a phase II trial looking at the safety of MVA85A vaccination in latent TB64 to trends in the diagnosis of extrapulmonary TB65 and an evaluation of the association of new diagnosis with immigration profiles.66 The BTS Young Investigators Prize was awarded for research showing the importance of Oncostatin M in inducing matrix metalloproteinases (MMP) which drives matrix degradation and cavitation in TB.67 A national survey on contact tracing was presented68 and experience of contact tracing of farm workers who had been in contact with bovine TB discussed.69 New diagnostic and treatment monitoring techniques were highlighted, including the use of the Elispot test in the detection of active70 and latent71 TB and messenger RNA as a marker of treatment response in pulmonary TB.72
AND FINALLY….
The British Lung Foundation’s birthday was celebrated with an impressive review of important research findings over the last 50 years including the epidemiological studies that linked smoking with lung cancer, the development of the fibreoptic bronchoscope and more effective antituberculous therapy, and finally a look into the future potential for lung tissue regeneration. Congratulations are due to Drs Patel and O’Kane for their success in the Young Investigators prizes. Professor Malcom Green was awarded the BTS Honorary Medal for his notable contributions to respiratory physiological research and the establishment of the British Lung Foundation in 1985.
The new BTS President, Professor Peter Calverley, addressed the meeting and reflected on the achievements of the past. He went on to quote the poet Robert Frost:
“… and miles to go before I sleep”
and outlined his aspirations for the future direction of both clinical practice and research in respiratory medicine and the many challenges that lie ahead.
An overview of some of the key topics presented at the BTS Winter Meeting held in London in December 2005
REFERENCES
Footnotes
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Funding: none
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Competing interests: none declared