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Chronic obstructive pulmonary disease (COPD) causes load-capacity-drive imbalance in both wakefulness and sleep, principally driven by expiratory flow limitation and hyperinflation. Sleep imposes additional burdens to the respiratory muscle pump, driven by changes in respiratory muscle tone, neural respiratory drive and consequences of the supine position. COPD patients are therefore at higher risk of decompensation during sleep, which may manifest as altered sleep architecture, isolated nocturnal desaturation, sleep hypoventilation and restless legs. Each form of sleep disordered breathing in COPD is associated with adverse clinical and patient-reported outcomes, including increased risk of exacerbations, hospitalisation, cardiovascular events, reduced survival and poorer quality of life. COPD-obstructive sleep apnoea (OSA) overlap syndrome represents a distinct clinical diagnosis, in which clinical outcomes are significantly worse than in either disease alone, including increased mortality, risk of cardiovascular events, hospitalisation and exacerbation frequency. Sleep disordered breathing is under-recognised by COPD patients and their clinicians, however early diagnosis and management is crucial to reduce the risk of adverse clinical outcomes. In this narrative review, we describe the pathophysiology of COPD and physiological changes that occur during sleep, manifestations and diagnosis of sleep disordered breathing in COPD and associated clinical outcomes.

Home non-invasive ventilation (NIV) is central in the management of chronic hypercapnic respiratory failure and is associated with improvements in clinically relevant outcomes. Home NIV typically involves delivery of fixed positive inspiratory and expiratory airway pressures. These pressures do not reflect physiological changes to respiratory mechanics and airway calibre during sleep, which may impact on physiological efficacy, subsequent clinical outcomes, and therapy adherence. Novel ventilator modes have been designed in an attempt to address these issues. Volume-assured pressure support modes aim to automatically adjust inspiratory pressure to achieve a pre-set target tidal volume. The addition of auto-titrating expiratory pressure to maintain upper airway calibre is designed for patients at risk of upper airway collapse, such as obese patients and those with obstructive sleep apnoea complicating their hypercapnic failure. Heterogeneity in setup protocols, patient selection and trial design limit firm conclusions to be drawn on the clinical efficacy of these modes. However, there are data to suggest that compared to fixed-pressure NIV, volume-assured modes may improve nocturnal carbon dioxide, sleep quality and ventilator adherence in select patients. The use of the forced oscillation technique to identify expiratory flow limitation and adjust expiratory pressure to eliminate it is the most recent addition to these advanced modes and is yet to be assessed in formal clinical trials.

P101 Figure 1(A) Monthly mortality of patients under Lane Fox Respiratory Service follow-up, dotted lines represent upper and lower bounds of 95% confidence intervals (B) Proportion of home mechanical ventilation (HMV) users in each disease category who died between 1st March and 30th ApriI by year[Figure omitted. See PDF]ConclusionsDeaths amongst HMV users at our regional ventilation centre were highest in the first two months following the onset of the COVID-19 pandemic. A subsequent fall in mortality may relate to effective shielding advice following national lockdown and departmental guidance offered. The majority of deaths were in patients with obesity-related respiratory failure. These data support previous observations that obesity is a major risk factor for adverse outcomes in patients with COVID-19.

P136 Table 1Results of correlation analysis Correlation analysis 4MGS 1STSreps SpO2% desaturation Results r p-value r p-value r p-value Pre-COVID mMRC dyspnoea score 0(0–1) -0.267**

Neural respiratory drive (NRD), as reflected by change in parasternal muscle electromyogram (EMGpara), predicts clinical deterioration and safe discharge in patients admitted to hospital with an acute exacerbation of COPD (AECOPD). The clinical utility of NRD to predict the long-term outcome of patients following hospital admission with an AECOPD is unknown. We undertook a post hoc analysis of a previously published prospective observational cohort study measuring NRD in 120 patients with AECOPD. Sixty-nine (57.5%) patients died during follow-up (median 3.6 years). Respiratory failure was the most common cause of death (n=29; 42%). In multivariate analysis, factors independently associated with an increased mortality included NRD (HR 2.14, 95% CI 1.29 to 3.54, p=0.003), age (HR 2.03, 95% CI 1.23 to 3.34, p=0.006), PaCO2 at admission (HR 1.83, 95% CI 1.06 to 3.06, p=0.022) and long-term oxygen use (HR 2.98, 95% CI 1.47 to 6.03, p=0.002). NRD at hospital discharge could be measured in order to assess efficacy of interventions targeted to optimise COPD and reduce mortality following an AECOPD.Original clinicaltrial.gov number:NCT01361451

Exacerbations of COPD remain a leading cause of emergency hospitalisations worldwide, and up to 28% of patients are readmitted within 30 days of discharge [1]. Recent analyses of more than 2.3 million COPD hospitalisations highlight the dynamic and time-dependent nature of readmission risk, which peaks within the first 72 h of discharge [2, 3]. Effective readmission prevention strategies remain elusive and recognition of re-exacerbations beyond daily symptom variability is challenging for both patients and clinicians. Promotion of transitional care services and 30-day readmission penalties implemented by policymakers worldwide have had limited impact [4]. Telemonitoring strategies incorporating symptom and vital observation monitoring (peripheral oxygen saturation (SpO2), heart rate, respiratory frequency) have consistently failed to demonstrate beneficial effects on hospitalisation risk [5]. Objective physiological monitoring has been explored using the forced oscillation technique. However, this also failed to prolong time to first hospitalisation [6]., Physiological phenotyping using daily home-based assessments reveals early improvement in load–capacity–drive imbalance following #AECOPD and feasibility of home parasternal electromyography measurement, which tracks symptoms, health status and spirometry https://bit.ly/3o6I0Ty

Sleep disturbances are common in pregnancy and affect sleep quality. The maternal body is going through constant physical and physiological changes to adapt to the growing fetus. Sleep disorders may manifest at any point during pregnancy; some may result in adverse maternal or fetal outcomes. A strong clinical suspicion is crucial to identify sleep disorders in pregnancy and their management should be evaluated with a multidisciplinary team approach. In this review, we provide an overview of changes in sleep during pregnancy and summarise the key features of common sleep disorders in pregnancy, including practical tips on their management.Educational aimsTo provide an overview of common sleep disorders in pregnancy and their management options.To highlight the impact of the physiological changes in pregnancy on sleep.To outline the type of sleep studies available to investigate sleep disorders in pregnancy.

Introduction The 'Long COVID' syndrome, where symptoms persist beyond the acute illness with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19), is anecdotally described However, a comprehensive report of clinical, radiological, functional and psychological recovery from COVID-19 is currently lacking We present a detailed radiological, patient-reported and physiological characterisation of patients attending face-to-face assessment following hospitalisation with COVID-19 pneumonia Methods Prospective single-centre observational cohort study at an inner-city South London teaching hospital All patients admitted with severe COVID-19 pneumonia (admission duration-48 hours, oxygen requirement-40% or critical care admission) were invited to attend Post-COVID Clinic 6-8 weeks following hospital discharge Primary outcome: Radiological resolution of COVID-19 pneumonitis Secondary outcomes: Demographics and anthropometrics, inpatient clinical course, patient-reported and physiological outcomes at follow-up (symptoms, functional disability, mental health screening, 4-metre gait speed (4MGS), 1-minute sit-to-stand (STS) test) Results 119 consecutive patients attended clinic between 3rd June and 2nd July 2020, at median (IQR) 61 (51-67) days post discharge Baseline characteristics are presented in table 1 Despite apparent radiographic resolution of lung infiltrates in the majority (RALE score

Introduction Conventional lung function testing involves forced expiratory manoeuvres which risk aerosolisation of respiratory droplets and nosocomial transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19) Between-patient decontamination procedures render routine testing impractical Parasternal electromyography (EMGpara) is an effort-independent method of assessing inspiratory muscle activity that tracks clinical trajectory in COPD, cystic fibrosis and pulmonary fibrosis We evaluated EMGpara as a method of monitoring respiratory muscle function during recovery from COVID-19 pneumonia in Post-COVID clinic Methods Prospective single-centre observational cohort study (05/Q0703/82) All patients hospitalised with severe COVID-19 pneumonia (oxygen requirement-40% or critical care admission) were invited to clinic 6-8 weeks post-discharge EMGpara was recorded in consecutive patients attending 12 clinic sessions using transcutaneous second intercostal space electromyography Measurements were made over 2 minutes of tidal breathing followed by maximal inspiratory manoeuvres (inspiration to total lung capacity and maximal sniff manoeuvres) and the values for root mean square (RMS) EMGpara per breath, EMGpara%max (RMS EMGpara as a proportion of volitional maximum), Neural Respiratory Drive Index (NRDI) and sex-specific standardised residuals (z-scores) recorded After each measurement, equipment was decontaminated using alcohol-based wipes and surface electrodes were disposed of Symptom questionnaires and radiographic assessment of lung oedema (RALE) scores were recorded Results Between 4th June and 2nd July 2020, EMGpara was measured in 25 patients All approached patients consented to participate, no adverse events occurred Mean±SD age 57 1 ±15 6 years, 64% male, BMI 29 4±5 6 kg/m2, 29% current/ex-smokers mMRC was at pre-COVID baseline in 56%, 32% reported persistent burdensome breathlessness Respiratory rate 15±3 breaths/minute, oxygen saturation 98±2 0%, heart rate 87±12 bpm EMGpara measures are presented in table 1 Zscores of all EMGpara indices were raised NRDI was associated with admission, worst inpatient and follow-up RALE scores (R=0 41 (p=0 04), R=0 40 (p=0 046) and R=0 49 (p=0 01), respectively), not mMRC (R=0 24, p=0 24 Conclusions Inspiratory muscle activation was high, which may reflect underlying interstitial pathology, critical illness myopathy, deconditioning or anxiety relating to clinic attendance Parasternal electromyography is a well-tolerated technique that avoids aerosolisation of respiratory droplets and utilises equipment that is easily decontaminated between patients This makes it a practical and informative measure of lung function during the COVID-19 pandemic

EMGpara non-invasively quantifies neural respiratory drive, which reflects respiratory muscle load-capacity. It provides insights into ventilation optimisation, monitors treatment response and predicts treatment success in certain settings. Acceptable inter-observer reproducibility of EMGpara analysis between different centres would support future multicentre studies. Methods: 10 datasets were randomly selected for analysis from Labchart software(ADI,UK).Inter-observer reproducibility of EMGpara analysis was performed between Glasgow Sleep and Breathing Support Research Centre(GSBSRC) and the Lane Fox Clinical Respiratory Physiology Research Centre with EMGpara%max and its product Neural Respiratory Drive Index(NRDI). Results: Bland Altman analysis demonstrates good reproducibility of EMGpara%max and NRDI(Fig1). Pearson correlation analysis shows a strong correlation between EMGpara%max(r=0.9789,p Conclusion: These data demonstrate acceptable interobserver reliability of EMGpara measurement, endorsing future multi-centre studies utilising EMGpara as an advanced physiological biomarker.

Purpose of review Breathlessness is a common symptom in many chronic diseases and may be refractory to pharmacotherapy. In this review, we discuss the pathophysiology of breathlessness and the role of positive airway pressure (PAP) devices to ameliorate it. Recent findings Breathlessness is directly related to neural respiratory drive, which can be modified by addressing the imbalance between respiratory muscle load and capacity. Noninvasive PAP devices have been applied to patients limited by exertional breathless and, as the disease progresses, breathlessness at rest. The application of PAP is focussed on addressing the imbalance in load and capacity, aiming to reduce neural respiratory drive and breathlessness. Indeed, noninvasive bi-level PAP devices have been employed to enhance exercise capacity by enhancing pulmonary mechanics and reduce neural drive in chronic obstructive pulmonary disease (COPD) patients, and reduce breathlessness for patients with progressive neuromuscular disease (NMD) by enhancing respiratory muscle capacity. Novel continuous PAP devices have been used to maintain central airways patency in patients with excessive dynamic airway collapse (EDAC) and target expiratory flow limitation in severe COPD. Summary PAP devices can reduce exertional and resting breathlessness by reducing the load on the system and enhancing capacity to reduce neural respiratory drive.

Chronic obstructive pulmonary disease (COPD) remains a common cause of morbidity and mortality worldwide. Patients with COPD and respiratory failure, whether acute or chronic have a poorer prognosis than patients without respiratory failure. Non-invasive ventilation (NIV) has been shown to be a useful tool in both the acute hospital and chronic home care setting. NIV has been well established as the gold standard therapy for acute decompensated respiratory failure complicating an acute exacerbation of COPD with reduced mortality and intubation rates compared to standard therapy. However, NIV has been increasingly used in other clinical situations such as for weaning from invasive ventilation and to palliate symptoms in patients not suitable for invasive ventilation. The equivocal evidence for the use of NIV in chronic hypercapnic respiratory failure complicating COPD has recently been challenged with data now supporting a role for therapy in selected subgroups of patients. Finally the review will discuss the emerging role of high flow humidified therapy to support or replace NIV in certain clinical situation.

Humidified high-flow therapy (HFT) is a noninvasive respiratory therapy, typically delivered through a nasal cannula interface, which delivers a stable fraction of inspired oxygen (FIO2) at flow rates of up to 60 L·min−1. It is well-tolerated, simple to set up and ideally applied at 37°C to permit optimal humidification of inspired gas. Flow rate and FIO2 should be selected based on patients' inspiratory effort and severity of hypoxaemia. HFT yields beneficial physiological effects, including improved mucociliary clearance, enhanced dead space washout and optimisation of pulmonary mechanics. Robust evidence supports its application in the critical care setting (treatment of acute hypoxaemic respiratory failure and prevention of post-extubation respiratory failure) and emerging data supports HFT use during bronchoscopy, intubation and breaks from noninvasive ventilation or continuous positive airway pressure. There are limited data on HFT use in patients with hypercapnic respiratory failure, as an adjunct to pulmonary rehabilitation and in the palliative care setting, and further research is needed to validate the findings of small studies. The COVID-19 pandemic raises questions regarding HFT efficacy in COVID-19-related hypoxaemic respiratory failure and concerns regarding aerosolisation of respiratory droplets. Clinical trials are ongoing and healthcare professionals should implement strict precautions to mitigate the risk of nosocomial transmission. Educational aims Provide a practical guide to HFT setup and delivery. Outline the physiological effects of HFT on the respiratory system. Describe clinical applications of HFT in adult respiratory and critical care medicine and evaluate the supporting evidence. Discuss application of HFT in COVID-19 and aerosolisation of respiratory droplets., Humidified high-flow therapy is a well-tolerated method of delivering a stable FIO2 at flow rates up to 60 L/min. It improves secretion clearance, dead space washout and pulmonary mechanics and is an effective treatment in hypoxaemic respiratory failure https://bit.ly/35Hvjrj

Introduction: NRD can predict safe discharge following an AECOPD. Our aim was to assess if NRD could predict long term mortality. Methods: Post-hoc analysis of a prospective cohort. NRD was assessed by parasternal EMG and was measured at hospital admission and at discharge. EMGpara%max was defined as the ratio between EMGpara during tidal breathing and during sniff manoeuvre. Results: Of 120 patients, 69 (57.5%) died. Mean follow up was 3.3±1.8years. The cause of death was attributable to respiratory disease in the majority of cases (n=29, 40%). At discharge, an EMGpara%max >14.84% was associated with a significantly worse prognosis with a median survival of: 998 days vs. 2002 days when it was below (HR 1.89 [95%CI 1.20 – 3.10], p=0.009, log-rank) (Figure 1). In multivariate analysis, factors associated with a poor prognosis were: EMGpara%max at discharge >14.84% (HR 2.15 [95%CI 1.30 – 5.55], p:0,003), age >71 years (HR 2.04 [95%CI: 1.24 – 3.35], p:0.005), a PaCO2 at admission >5.56 kPa (HR 1.81 [95%CI: 1.08 – 3.03], p:0.015) and previous long term oxygen use (HR 3.34 [95%CI 1.69 – 6.61], p:0.001). Conclusion: Our post-hoc analysis suggests that discharge NRD is an independent predictor of long term mortality in patients following admission for an AECOPD. Future work should investigate the benefit of targeting modifiable factors such as NRD and PaCO2 following AECOPD. 1-Suh E-S. Thorax 2015;70:1123–30

Neurocysticercosis (NCC) is a parasitic infection with the larvae of Taenia solium from contaminated pork. It is a leading cause of seizures in the developing world. Symptoms may be secondary to live or degenerating cysts, or previous infection causing calcification or gliosis. Diagnosis is based on clinical presentation, radiological confirmation of intracranial lesions and immunological testing. Management involves symptom control with antiepileptics and antiparasitic agents. Few cases have been described of maternal NCC during pregnancy. We describe a 25-year-old female presenting to a London hospital with secondary generalized seizures. MRI of the brain confirmed a calcified lesion in the right parietal lobe, and she gave a corroborative history of NCC during her childhood in India. She was stabilized initially on antiepileptics, but during her pregnancy presented with breakthrough seizures and radiological evidence of NCC reactivation. She was managed symptomatically with antiepileptics and completed the pregnancy to term with no fetal complications.

Aims: • Evaluate the use of lumbar puncture (LP) in the Acute Medical Department of a typical urban district general hospital. • Increase the proportion performed on appropriate patients. Methodology: An observational, single-centre, retrospective examination of patients undergoing LP at Solihull Hospital over four consecutive months. Discussion of findings and LP indications with the Acute Medicine Department. Re-audit over four months. Results: Total LPs performed fell by 65%. The proportion performed on patients presenting with red flags rose by 19% (p=0.0098). The proportion that yielded positive findings rose by 33% (p

Introduction: Use of thrombolysis in the management of pulmonary embolism (PE) is currently based on the European Society of Cardiology guidelines which use shock and right ventricular (RV) dysfunction as indications (Konstantinides, S.V. et al . European Heart Journal 2014;35:3033-3080). Thrombolysis in the absence of cardiovascular compromise remains controversial. Aim: To identify whether respiratory failure should be an indication for thrombolysis in PE. Methods: A retrospective single-centre cohort study. PE cases were identified from CT pulmonary angiogram reports over a 12 month period. Thrombolysed cases were identified from medical records. Results: 280 cases of PE were diagnosed between 01/12/2014-30/11/2015. 7 were thrombolysed. At the time of thrombolysis, mean respiratory rate was 28 (data incomplete for 2). 6 had arterial blood gas sampling, revealing type 1 respiratory failure in all. PaO 2 was 100bpm. 86% had CT or echocardiographic evidence of RV dysfunction. Serum troponin was raised in 71%. 3 cases died within 30 days of thrombolysis. The remaining cases survived to discharge and remain alive at the time of reporting (at least 3 months survival). Conclusions: Current guidelines exclusively use cardiovascular parameters to guide thrombolysis in PE. In this study, more than half of the thrombolysed cases were not hypotensive whilst all were hypoxic and tachypnoeic. Our experience suggests that greater emphasis should be placed on markers of respiratory compromise when risk stratifying in PE and that further research is needed to guide clinicians9 use of thrombolysis outside of currently accepted scenarios.

Weaning from mechanical ventilation is an ill-defined process. The 2007 International Consensus Conference (ICC) weaning definition is difficult to apply as it uses spontaneous breathing trials (SBT) which are not universally used and excludes tracheostomised patients and those who fail to wean or die. In this prospective, multinational observational study, Beduneau et al propose a weaning classification for utilisation in daily practice for all mechanically ventilated patients ( Am J Respir Crit Care Med 2017;195:772–83). 2709 intubated patients from 36 European intensive care units (ICUs) were observed until ICU discharge or day 60. The authors propose a classification based on weaning duration from first separation attempt (extubation or SBT in intubated patients or ≥24 hours spontaneous ventilation in tracheostomised patients). Group ‘no weaning’ (24%) had no separation attempt; group 1 (57%) weaned in 1 and