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In this paper, super-wideband antenna with reconfigurable characteristics for multiple wireless applications is investigated. Proposed antenna consists of guitar shape radiating patch and chamfered rectangular ground plane with rectangular slot. In order to mitigate the interference caused by existing wireless system (WiMAX, WLAN and downlink satellite system), reconfigurable band stop filters corresponding to interfering bands are generated on the radiating patch by using RF PIN diodes. Antenna covers super-wideband of 3.36–39.61 GHz (ratio bandwidth of 11.78:1) with overall of the dimension 27 × 32 × 0.787 mm3 and occupies comparably less space. Antenna is also investigated in frequency, time and spatial domain with nearly stable radiation patterns with suppression of gain and efficiency at interfering bands.

In this research article, a beetle shape Multiple-Input-Multiple-Output (MIMO) antenna including dual notched band characteristics are presented for different wireless band applications (UWB, X-Band and Ku Band) which are also experimentally and computationally investigated. A single evoluation antenna is demonstrated which is than converted to MIMO configuration to overcome the demerits when placed in communication channel. The overall volume of the proposed antenna is 25 × 48 × 0.787 mm3 printed on Rogers RT Duroid5870. Dual notched bands are obtained by etching an L-shaped slot on a radiating patch for WiMAX interference and satellite Downlink System interference (DSS) is removed by placing pair of C-shaped parasitic elements near the feed line. The proposed antenna offers measured isolation between two ports less than − 20 dB in entire operating bandwidth (2.57–19.15 GHz). At non-radiating mode, the radiation efficiency of antenna drops down due to the insertion of stop and filters. The wider impedance bandwidth of the antenna suggest that it is not only capable of working in UWB range but also finds applications in X- and Ku-Band applications allocated for Satellite and RADAR. An antenna is also reconfigured using PIN diodes to control each notched bands independently. Proposed MIMO antenna also offers better diversity performance in terms of ECC 9.95 dB, TARC

Introduction Following the outbreak of COVID-19, and the suspension of face to face activity, Pulmonary Rehabilitation (PR) services have had to think differently around service provision and alternative ways of delivery. Although there is wide variability in internet access and confidence by service users1, remote models of PR became a popular option. Methods SPACE for COPD® web programme was offered to PR services. Telephone or video training was provided by the SPACE for COPD team at UHL NHS trust. Clinical services were then set up to be able to give their patients access, monitor and progress them ‘remotely’ via the admin site. A staff survey was sent to services that signed up to use the web programme to understand their perceptions on using platform as part of their service. Results 191 enquiries were received in total (176 from the UK; 15 overseas); 73 clinical services were set up with over 600 patients accessing the on-line programme. Of the 24 survey responses, 91.7% of staff found the admin website user friendly. 16.7% had problems logging on to the admin site, but were resolved. 87.5% had no problems navigating the admin site. All staff found creating registration codes for patients easy to complete. 68.2% found the patient registration process easy to input and follow. 54.2% of staff said that patients found the website accessible and acceptable to use. 87% said that the walking and strength diaries were easy to input and navigate. 79.2% of staff stated that the remote training gave sufficient information and support when setting up SPACE for COPD. Discussion Over the last few months the uptake of SPACE FOR COPD shows there is a place and need for digital programmes. It has been an exciting opportunity to be able to share this and hopefully may even be an alternative option to offer patients in the future. Reference Polgar O., Aljishi M, Barker, et al. ( 2020). Digital habits of PR service-users: implications for home-based interventions during the COVID-19 pandemic. Chronic Respiratory Disease. https://doi.org/10.1177/1479973120936685

Introduction and Objectives Pulmonary rehabilitation (PR) is an evidence-based treatment for patients with COPD. However, the national audit reveals significant under-referral and uptake to the programme,1 which will likely continue during the Coronavirus Disease 2019 (COVID-19) pandemic because of restrictions to PR delivery. At University Hospitals of Leicester NHS Trust (UHL) a choice of centre-based and home-based programmes exist to support individual patient needs but are not routinely offered at referral. To support referral and uptake to PR, exploring the barriers and facilitators to the current approach and a new menu-based approach to PR is warranted. Methods Individual, semi-structured interviews were conducted with respiratory healthcare professionals (rHCPs) who refer patients with COPD to PR and COPD patients who were PR naive and had received a referral. Interviews were audio-recorded, transcribed verbatim and analysed using The Enhanced Critical Incident Technique.2 Categories were generated to reflect helping, hindering and wish list items, then validated and reviewed by a collaborating and independent expert. Results 22 participants were recruited (rHCPs=14; COPD patients=8). 276 critical incidents generated 108 hindering, 108 helping and 60 wish list categories. The identified mediators of PR engagement were: Understanding PR/menu-based programmes, Perceived ability to access PR, A desire to accept PR, A referring practitioner’s support of PR, and Understanding COPD (see figure 1). Conclusion The menu-based approach offers increased opportunity for patients to engage in PR particularly during the COVID-19 pandemic. However, its poor identity limits its feasibility and acceptability. Building the identity of COPD, PR/menu of programmes, further integrating PR in COPD care and developing tools to illicit patient-centred discussions is recommended. The findings support the development of a shared decision making intervention to facilitate patient-centred discussions regarding the menu of PR programmes available at UHL. References Steiner M, Holzhauer-Barrie J, Lowe D, Searle L, Skipper E, Welham SRC ( 2015). National COPD Audit Programme: Pulmonary Rehabilitation: Time to breathe better. Butterfield LD, Borgen, WA, Maglio, A-ST, & Amundson NE. ( 2009). Using the Enhanced Critical Incident Technique in Counselling Psychology Research. In Canadian Journal of Counselling/Revue canadienne de counseling (Vol. 43).

Introduction It is reported that 2.7–33% of patients with COPD report sputum retention. This disparity is due to variability in outcomes. Current measures of sputum retention are labour intensive and with large variance, therefore there is a need for an objective measure. This study aims to explore the use of the Lung Clearance Index (LCI) as a surrogate measure of sputum clearance. Methods Participants were recruited to complete the LCI as part of a randomised controlled trial. Participants used an oscillating device or a placebo for eight weeks. The LCI was derived from a multiple breath washout using an open circuit Innocor system using 0.2% sulphur hexafluoride (SF6). Participants breathed at tidal volumes and the washout was performed on room air. The test was terminated with participants reached 1/40th of the starting concentration. From the multiple breath washout the LCI and conducting and acinar slopes were analysed (Scond/Sacin) Results 104 participants were recruited to this study. 53% of participants reported ≥3 on the COPD assessment test (CAT) sputum scale. Patients with ≥3 or Conclusion During the study phase, both groups saw a worsening of their LCI however those receiving the active treatment had a better preservation of this. The Sacin improved greater in those using the active treatment and this was amplified when analysed in those with higher self-reported sputum.

Background Eccentric cycling (ECC) may be an attractive exercise modality in COPD due to lower cardiorespiratory demand and perception of effort compared to conventional concentric cycling (CON) at equivalent mechanical workloads. However, it is unknown whether ECC can be performed by individuals with COPD at an intensity able to induce metabolic adaptation. Methods 13 individuals with COPD (mean ± SD age 64 ± 9 years, FEV1%pred 45 ± 19%, BMI 24 ± 4 kg.m-2, VO2peak15 ± 3 ml.kg-1.min-1) and 9 age matched controls (FEV1%pred 102 ± 13%, BMI 28 ± 5 kg.m-2, VO2peak23 ± 5 ml.kg-1.min-1), performed up to six 4-minute bouts of ECC and CON at matched mechanical loads of increasing intensity. In addition, 12 individuals with COPD underwent quadriceps muscle biopsies (vastus lateralis) before and immediately after 20 minutes of ECC and CON at 65% peak power. Modalities were compared using linear mixed models. Results The gradient of the slope of VO2 (ml.min-1)/Power (Watts) during ECC was 2.8-fold and 3.3-fold lower than CON for COPD and control participants, respectively. At matched mechanical loads, minute ventilation, heart rate, systolic blood pressure, RER (all p Conclusion Cardiopulmonary and blood lactate responses during submaximal ECC were less compared to CON at equivalent mechanical workloads in health and COPD, and this was confirmed at a muscle level in COPD. Submaximal ECC was well tolerated and allowed greater mechanical work at lower ventilatory cost. However, in people with COPD, the lower metabolic cost of ECC is unlikely to stimulate cardiovascular and metabolic adaptation to a training intervention to the same extent as CON.

Introduction Current WHO physical activity guidelines recommend adults accumulate ≥150 minutes per week of moderate intensity activity in bouts of ≥10 minutes. We aimed to compare daily physical activity levels and intensity of physical activity between adults with severe asthma and healthy controls. Methods Adults with severe asthma, defined by step 4/5 of the BTS/SIGN guidelines, under the care of a difficult asthma service at a tertiary centre, and age and sex-matched health controls were recruited. Age, gender, smoking status, and medication were recorded, and BMI calculated. Daily physical activity was measured for seven days using a SenseWear Pro-3armband triaxial accelerometer. Adequate wear time was defined as ≥eight hours per day for a valid day with a minimum of four valid days. Steps, stationary time, time spent in moderate-vigorous activity (MVPA) and MVPA in ≥10 minute bouts were analysed adjusted for wear time. Analysis of co-variance (ANCOVA) was used to adjust for covariates. Results 48 people with severe asthma (35% male, mean [SD] age 55 [13] years, 25% ex-smokers, 4% current smokers,50% prescribed oral steroids) and 48 age and sex-matched healthy participants (29% ex-smokers, 0 current smokers) completed the study. Mean [SD] BMI was higher for patients with severe asthma (33.0 [6.7] kg/m2) compared to healthy participants (26.4 [4.4]) kg/m2), p Conclusion Patients with severe asthma perform fewer steps and fewer 10 minute bouts of MVPA per day compared to their healthy peers, whereas time spent stationary was similar. Advice and interventions to increase physical activity in people with severe asthma should target MVPA.

In this manuscript, compact monopole antenna with multiband characteristics is presented. Proposed antenna is fabricated on Silicon Substrate with CPW feed. Radiating patch consist balloon shape with modified ground plane. Multiband functional antenna is obtained by embedding stubs on radiating and etching slots in ground plane. Lower band applications including Universal Mobile Telecommunication System 2100 (UMTS: 1.92GHz-2.17GHz), Long-term Evaluation 2.30GHz (2.305GHz-2.400GHz), 2.60GHz (2.500GHz-2.690GHz) & WiMAX Band (3.30GHz-3.80GHz) are obtained due to embedded stubs. WLAN Band (5.150GHz-5.825GHZ) and X Band Downlink System (7.25GHz-7.75GHz) are obtained by etching slots. Also antenna features such as compact size (15×15mm2), omnidirectional radiation pattern and contant gain throughout operating band.

Background It is widely reported that individuals with COPD frequently present with co-morbidities. Osteoarthritis is an important co-morbidity that may affect an individual’s ability to participate fully in pulmonary rehabilitation (PR). There is little data exploring the impact of osteoarthritis upon PR. Aim To explore the prevalence and impact of hip and knee pain in patients attending PR and the impact of PR, that could be either detrimental or advantageous upon joint pain. Methods Patients completed standard PR outcome measures, including the Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walk Test (ESWT) and the COPD Assessment Test (CAT). The Oxford Hip and Oxford Knee questionnaires1 2 were also completed for all 4 joints pre and post PR. These questionnaires are validated, 12-item, patient reported outcome measures with a single composite score to describe the perception and impact of joint pain, over the last 4 weeks.10 represents the most perceived pain and 48 the least perceived pain. Patients participated in a 6 week outpatient PR programme, comprising supervised exercise and group-based education. This included an individually prescribed walking programme, cycling and upper and lower-limb strength training. Patients also completed an unsupervised home-exercise programme. Results n=68 attended a PR assessment (COPD n=47, bronchiectasis n=6, asthma n=5, ILD n=7, other n=3), 55.6% male; mean age 68.7±10.2 years. At baseline, 15 patients reported knee pain, 10 reported hip pain and 17 reported both hip and knee pain (62% of patients assessed). Post PR, hip and knee pain scores improved but only improvements in right knee pain reached significance (p Conclusion A significant number of participants presented with joint pain at the time of initial assessment for PR. Overall, participants improved their exercise capacity and reduced their symptom burden from their COPD. PR was not detrimental to joint pain. Alongside increases in exercise capacity, we observed slight improvements in joint pain.

Introduction and objectives Hospital admissions due to AECOPD are costly to the individual and the health service. Pulmonary Rehabilitation (PR) is a package of education and exercise, known to reduce hospital readmissions when delivered after hospitalisation. Despite these benefits, the completion of PR following hospitalisation is The primary aim of this study was to assess the feasibility of the web-based programme for individuals hospitalised with an AECOPD. Methods Eligible patients had confirmed COPD, were web-literate and had an email address. All patients were consented during their hospitalisation and received access to the website for 12 months following discharge, in addition to usual care. The programme facilitates patients to better understand and manage their condition through education and home-based exercises. The primary outcome was the proportion of screened patients consenting to the programme. We also collected web usage statistics and PR uptake at 6 months. Results 2080 patients were screened for eligibility between May 2015–Sep 2017 of which 100 patients (71.2±9.3 years, 55% male, FEV1/FVC ratio 0.46±0.14, 50.2±31.0 pack years) were recruited (4.8% of those screened). The main reason for ineligibility was lack of web-literacy. 18% had completed the web programme by 6 months, with others still registered on the programme (27%) and over half not registering (55%). Of those accepting a referral to PR on discharge (57%), 19% completed the programme. Conclusion Based on the challenges to recruit, retain and engage participants in the web-based self-management programme, it is not a feasible approach to roll out widely. However, for patients able to engage with such an intervention, the completion of PR was double the previous audit estimate1. Therefore, with further refinement, web-based strategies may be a viable stepping stone to PR. Identifying those patients most likely to benefit from web-based programmes is needed. References Jones, et al. Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: Referrals, uptake and adherence. Thorax2013;69(2):181–2. Chaplin, et al. Interactive web-based pulmonary rehabilitation programme: A randomised controlled feasibility trial. BMJ Open2017;7:e013682.

Background National guidance for COPD suggests that self-management support should be provided for all patients.1 We have previously developed a manual-based, supported self-management programme: Self-Management Programme of Activity Coping and Education-SPACE for COPD. Having previously piloted SPACE for COPD on a one-to-one basis,2 stakeholders are also interested in delivering SPACE for COPD as a group-based programme facilitated by healthcare professionals (HCPs) within primary care. Aims To examine whether group-based delivery of SPACE for COPD improves patient outcomes. Methods A prospective, single-blinded, Randomised Controlled Trial was conducted, with follow-up at 6 months (6 M). Participants were assigned to a control (usual care) or intervention group (six-session, group-based SPACE for COPD delivered over 5 months). The primary outcome was symptom burden (COPD Assessment Test (CAT)). Secondary outcomes were knowledge (Bristol COPD Knowledge Questionnaire), quality of life (Chronic Respiratory Questionnaire (CRQ); EuroQol 5-Dimension), mood (Hospital Anxiety and Depression Scale), patient activation (Patient Activation Measure (PAM)) and exercise capacity (Incremental Shuttle Walk Test (ISWT); Endurance Shuttle Walk Test (ESWT)). Two-way ANOVAs were conducted to examine within-and between-group differences in outcomes. Results 122 participants completed the CAT at baseline (BL) and 6 M (72% male, 70.7±8.2 years). CAT did not change between baseline and 6 M, and was not different between groups (intervention:15.0±7.6 vs 15.6±8.0; control:13.6±6.1 vs 15.6±7.8, p=0.181, for BL and 6 M respectively; table 1). Knowledge (intervention: 34.0±7.6 vs 37.6±7.8; control: 32.9±7.4 vs 33.8±8.2, p=0.027), CRQ fatigue (intervention:4.6±1.2 vs 4.8±1.4; control:4.7±1.2 vs 4.5±1.3, p=0.034), CRQ mastery (intervention:5.7±1.2 vs 6.0±1.1; control:5.9±1.1 vs 5.8±1.2, p=0.032), and patient activation (intervention:58.4±11.2 vs 63.5±15.3; control:59.7±10.6 vs 59.5±11.5, p=0.023) all significantly improved in the intervention group compared to the control group. Exercise capacity improved for the intervention group (ISWT: 413±155 vs 440±164, p=0.018; EWST: 497±397 vs 652±455, p Conclusions The SPACE for COPD intervention does not improve CAT, but does improve exercise capacity, patient activation, knowledge and quality of life domains ‘fatigue’ and ‘mastery’, when delivered as a group-based intervention by HCPs in the community. References NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE2010:CG101. Mitchell K, et al. A self-management programme for COPD: A randomised controlled trial. Eur Respir J European Respiratory Society 2014;44:1538–47.

Background Despite the known benefits of post exacerbation Pulmonary Rehabilitation (PR), recruitment can often be difficult. A greater understanding of the reasons why patients hospitalised for an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) declined the offer of PR is important. Methods Patients (n=76) admitted to hospital with an AECOPD received a COPD care bundle delivered by COPD specialist nurses. From July to December 2015 patients receiving the care bundle who declined a referral to PR were asked for their reasons for declining. Hospital records were followed up in January 2017 to record admissions and mortality data since the first data collection. Results Mann Whitney U Tests were carried out to see if there were any differences between the main reasons (Table 1) for declining referral and age, MRC, pack years (PY) and/or co-morbidities. Participants who reported that they were not interested in doing PR had a statistically significantly higher PY history (60 vs. 43; p=0.02) compared to patients that chose another reason to decline PR. There was a significant difference between participants MRC scores and the reason they did not want to do PR. Those who did not feel they needed PR reported a lower MRC score range (2–4), compared with the participants in the other options for declining PR; MRC range (3–5);(p=0.005). Patients who gave the reason that felt they did not need PR had a statistically significantly lower number of admissions between their data collection periods (median 2.00 vs. 0.00; p=0.02). Patients who declined PR because they had previously completed the programme compared with those who gave other reasons, had a significantly higher number of hospital admissions during the follow up period (median 4.00 vs. 1.00 p=0.008). There was no statistically significant difference between the number of co-morbidities that patients had and the three main reasons given by patients for declining PR. Conclusions This data has demonstrated that there are some consistent reasons why people decline PR. Further research is required to identify whether changing how PR is discussed with patients may encourage and help us recruit these types of patients into the PR.

Introduction and Objectives Education is considered integral to a comprehensive pulmonary rehabilitation (PR) programme, intended to provide the underpinning knowledge base for behaviour change to improve and maintain positive outcomes. We aimed to explore staff perceptions of their knowledge, skills and confidence to deliver education topics to identify training needs if re-designing PR education. Methods 15 hospital-based (n=9) and community-based (n=6) multidisciplinary PR staff in Leicestershire completed a qualitative and quantitative questionnaire. The questionnaire comprised items relating to professional background and formal experience/training in delivering education. Likert scales (1=low level, 5=high level) were used to assess knowledge, skills and confidence in delivering 12 PR education topics (Exercise, Diet, Managing Breathlessness, Avoidance and Exacerbations, Signposting, Anxiety Management, Medication, Disease Education, Chest Clearance, Energy Conservation, Relaxation and Question and Answer) alongside open response questions. A ‘Yes/No’ item asked about skills to deliver more unstructured sessions. Mean rank was calculated using the frequency of ‘high-level’ scores across knowledge, skills and confidence (1=highest and 12=lowest). Friedman tests with post-hoc Wilcoxon Sign Rank tests compared knowledge, skills and confidence between education topics. Free text responses were also examined. Results The majority of staff were physiotherapists (73.3%) and had previous formal education training (66.7%). PR staff reported feeling most knowledgeable, skilled and confident to deliver Exercise, Managing Breathlessness and Disease Education (mean rank out of 12: 1.7, 2.0 and 3.0, respectively). PR staff reported feeling least knowledgeable, skilled and confident to deliver Medication, Diet and Anxiety Management (mean rank: 10.3, 11.0 and 11.7, respectively). Figure 1 displays median scores for knowledge, skills and confidence for each of the education topics. Anxiety Management and Diet had significantly lower scores compared with all other education topics (all p Conclusions If re-designing PR education, additional training should be provided for staff particularly around Diet and Anxiety Management and delivery style.

Introduction and Objectives Chronic Obstructive Pulmonary Disease (COPD) is characterised by expiratory flow limitation contributing to dyspnoea and impacting on exercise capacity and quality of life. Inspiratory muscle training is commonly used to improve inspiratory muscle strength and endurance, exercise capacity and quality of life. The High Frequency Airway Oscillating (HFAO) device uses flow resistance to provide combined inspiratory and expiratory muscle training. It is hypothesised that the use of a HFAO device may improve the strength of the respiratory muscles resulting in reduced sensation of dyspnoea. This study was designed to explore the feasibility of HFAO in COPD. Methods Patients with symptomatic COPD were included (MRC of ≥3). This was a single arm feasibility study using a HFAO device. All participants used the device for 5 min, 3 times per day, for eight-weeks. The primary outcomes were recruitment, attrition and compliance. Self-reported daily diaries identified participants as adherent if they completed ≥75% of device use. Secondary outcome measures included maximal inspiratory and expiratory pressures (Pi max /Pe max ), Incremental and Endurance Shuttle Walking Tests (ISWT/ESWT) and health related quality of life questionnaires. Data was analysed by a Wilcoxon Signed Rank test and considered statistically significant if p Results 23 participants with COPD were recruited (65% male, mean [SD] age 65[5] years, FEV 1 %predicted 44[16], FEV1/FVC ratio 0.46 [0.13]), median [IQR] MRC 4 [3–5], of which 20 participants completed the intervention. 62% of potential participants were recruited and there was an attrition rate of 13%. 90% of participants were considered adherent to device use. A significant improvement in MRC score (median change −1 [IQR 3–3]) was observed (p≥0.01). Significant improvements were seen in Pi max and Pe max (table 1). Pre and post intervention exercise performance and quality of life are shown in Table 1. Conclusions This shows promising Results in the use of HFAO to reduce dyspnoea within COPD. Recruitment and attrition was appropriate and compliance rates were considered suitable and therefore it is feasible to proceed to a randomised controlled trial.

Introduction and Objectives Hospitalisation for an exacerbation of chronic respiratory disease has a major impact on physical activity (PA). However, criteria to derive reliable inpatient PA data do not exist and current recommendations are unlikely to account for variations in length of hospital stay (LOHS) and the hospital environment. The aims were to identify the minimum wear time and number of days required to obtain reliable inpatient PA data; to use these criteria to determine how PA changes during recovery as an inpatient; and to compare PA across patients stratified by LOHS. Methods 259 individuals hospitalised with an exacerbation of chronic respiratory disease were recruited as part of an early rehabilitation trial previously reported (Greening et al, BMJ 2014). Participants (mean (SD) age 70.0±9.7 years, 58.3% female) wore a physical activity monitor (SenseWear) during their stay. Daily step count and walking time during waking hours was analysed. Inpatient PA was assessed across a range of minimum wear time criteria (≥1–12 hours). Repeated measures analysis of covariance was used to compare between days and between times of day. Single-day intraclass correlation coefficients (ICCs) were calculated across the range of wear time criteria. The minimum number of days required to obtain an ICC ≥0.80 was estimated using the Spearman-Brown prophecy formula. Results A minimum wear time of 11 hours (≥1 valid day) allowed 80% of the sample to be retained. All minimum wear time thresholds produced an ICC ≥0.80, resulting in 1 day of wear required to produce representative inpatient PA. Mornings and afternoons were more active than evenings and overnight (32.1% and 32.0% vs. 25.2% and 10.7% of steps/day, respectively, p Conclusions One full day (24 hours) of monitoring is required at the individual-level to obtain representative inpatient PA. A minimum wear time criteria of ≥11 waking hours is recommended for sample-level data. Wear time and LOHS should be accounted for in analyses.

In the BitTorrent peer-to-peer file sharing protocol, it is observed that when a group of peers known to each other (due to geographical proximity or otherwise) are aiming for the same file, it is downloaded by a single peer and then shared within the group or it is downloaded individually. This is an inefficient approach as the fidelity rests on one peer or all peers (promoting redundancy), thus resulting in wastage of bandwidth and time. In this paper, we propose a solution to counter these problems by encouraging equal participation of the peer group in the download process. We show how the bandwidth of each peer is utilized to the maximum (thus reducing download time) by segregating a file into smaller sized parts with each peer downloading a part of the file in parallel and then merging the individual parts to form the complete data. We also add to the above proposition how one peer can effectively resume the interrupted download of another peer, remotely. Using simulation, we validate and demonstrate the effectiveness of the proposed strategy by taking real world examples showing large amounts of data being transferred at massive speeds and in a very short period of time.

Introduction Several baseline factors influence the response to Pulmonary Rehabilitation (PR). The Incremental and Endurance shuttle walk test is used to prescribe an exercise walking speed for patients with a chronic respiratory disease as part of a PR programme. We wished to explore the speed and duration of baseline endurance performance and observe how this impacted upon changes post rehabilitation particularly around the higher speeds of the endurance shuttle walk test (ESWT). Methods Patients completed a 7 week outpatient PR programme comprising of both endurance and strength training. The endurance training is based on the ESWT speed which is 85% of the individual maximal capacity derived from the incremental shuttle walk test (ISWT). The ISWT and subsequent ESWT were performed at baseline and discharge. Patients were categorised into low ( 3.6 km/hr) speed walkers based on their baseline ESWT performance. Results 990 patients completed the SWT: 567 low speed walkers (mean age 70.9 ± 9.7 years; FEV 1 1.5 L ± 4.9; BMI 27.6 ± 9.0 kg/m 2 ; MRC 4 (IQR 3–4); ISWT pre 128.4 ± 61.6 m; ESWT pre 166.3 ± 161.5 secs) and 423 high speed walkers (mean age 67.8 ± 9.2 years; FEV 1 1.62 L ± 3.8; BMI 27.1 ± 14.0 kg/m 2 ; MRC 3(IQR 2–3); ISWT pre 373.4 ± 103.3 m; ESWT pre 262.4 ± 147.6 secs). Those walking at a higher speed had a significantly higher pre ESWT (p ≤ 0.001). A statistically significant improvement was observed in the ESWT within each group (low: mean change 344.2 ± 401.5 p ≤ 0.001; high: mean change 369.3 secs p ≤ 0.001). However the change in ESWT was not significantly different between the groups (p = 0.3). Conclusion Interestingly, those patients who walk at a faster speed have a greater baseline ESWT performance compared to those patients who walk at a slower endurance speed. However both groups made comparable changes in the ESWT following PR.

Introduction and objectives Despite the large socioeconomic burden of severe asthma, few studies have focused specifically on the patient experience of living with and managing severe asthma. Patient-related factors including behavioural, psychological and social factors complicate the management of the condition. This study aimed to explore these experiences in individuals with severe asthma to understand how to support effective self-management. Method Semi-structured interviews were conducted with participants recruited from a difficult asthma service at Step 4–5 of the BTS/SIGN guidelines. Recruitment occurred until theoretical saturation was achieved. Interviews were transcribed verbatim and coded, supported by NVivo software (Version 10). Thematic analysis was performed. 1 Results 29 interviews were completed (44% male, mean age 49.45 (13.64) years, BMI 31.65 (5.48) kg/m 2 , 4 smokers). Five themes describe the experience of living with and managing severe asthma: Impact of asthma. Debilitating breathlessness was described impacting on many areas of participants lives, including relationships, work and family life. Day to day management of asthma. Self-regulatory behaviours were described such as monitoring peak flow and pacing. However, these behaviours and the implied restrictions could induce distress and dissatisfaction. This limited self-management behaviours in-between the acute phases of illness. Confidence to manage symptoms. Participants reported confidence to manage acute events, but the unpredictability of symptoms and fear of inducing symptoms appeared to undermine their confidence to manage symptoms. Challenges to effective self-management. There were further multiple challenges to effective self-management, such as: understanding of disease; perceptions of asthma by others; reluctance to accept hospitalisation and the unpredictability of symptoms. Beliefs about medication. There was conflict around long term oral steroids. Most participants resolved this by balancing the necessity of the medication versus the concerns they held about the long term effects of maintenance. There was little comment regarding inhaled medications. Conclusion Strategies are needed to enhance acceptance and confidence to engage in self-management behaviours. This should encompass all aspects of the disease, not solely the acute phases, to minimise daily distress and increase effective self-management to improve the health status for this severe population. Reference 1 Braun V. Using thematic analysis in psychology. Qualitative Research in Psychology . 2006; 3 :77–101

Introduction Providing outpatient Pulmonary Rehabilitation (PR) following hospitalisation for an acute exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) has been found to improve exercise capacity, quality of life and a reduction in unplanned hospital admissions and mortality (Puhan, 2011). These positive effects, although studied in the short term, have led to national and international guidelines supporting the provision of post exacerbation PR (PEPR). However, uptake is poor with less than 10% of hospital discharges for AECOPD completing PEPR (Jones, 2014). The aim of this study was to establish whether delaying the offer of rehabilitation would be effective and acceptable to patients who have recently been hospitalised for an AE of their COPD. Methods A randomised controlled trial was conducted. Patients were randomised to PEPR or delayed PEPR (D-PEPR) following hospitalisation for an AECOPD. Both programmes were the same, consisting of twice weekly, six-week hospital based programme (exercise and education). PEPR commenced within four weeks of hospital discharge and D-PEPR commenced 7 weeks after this. The primary outcome was the Incremental Shuttle Walking test (ISWT), secondary measures were the Endurance Shuttle Walk Test (ESWT). Results Thirty six patients consented and were assessed (14 male, mean (SD) age 66.03 (7.64) years, FEV 1 1.18 (0.48) litres, ISWT 225 (160.77) metres, ESWT 222 (151.09) seconds. We observed important improvements in the PEPR group. However, only 6 patients out of 12 assessed in the D-PEPR group remained during the control time prior to the programme commencing of which 3 patients went on to complete all of D-PEPR (Table 1). Conclusion PEPR is effective and no natural recovery was observed. Although small numbers, acceptability and completion for D-PEPR was even worse than PEPR. D-PEPR does not seem a feasible alternative to PEPR. Reference 1 Puhan MA, Gimeno-Santos E, Scharplatz M. et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev . 2011; 10 :CD005305 2 Jones SE, Green SA, Clark AL. et al. Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: referrals, uptake and adherence. Thorax . 2014; 69 :181–2

Introduction The assessment of functional exercise capacity is important in the evaluation of patients with chronic conditions and field walking tests are often used to assess functional exercise capacity. The ISWT is one field exercise test which is often employed in the assessment of pulmonary and cardiac rehabilitation (PR, CR) patients and also to prescribe a walking speed. In PR and CR programmes the ISWT is employed to calculate walking speed set at a desired training threshold. The aim of the study was to establish reference values for the ISWT and an equation for its prediction in a healthy population. This will allow comparison between patients from PR and CR programmes and healthy age-matched controls. Methods Subjects were aged between 40 and 90 years, had normal spirometry defined as FEV 1 % pred >80% and/or a FEV 1 /FVC >70% and had no known co-morbidities affecting mobility. The best distance from two ISWT was recorded along with body mass index (BMI) and leg length. Quadriceps maximal voluntary contraction (QMVC: Kg) was measured using a strain gauge (Kern). Physical activity was assessed using the DUKE physical activity questionnaire and an activity monitor (SenseWear PRO 2 Armband). The number of steps and energy expenditure achieved over 2 days was recorded. Subjects also completed the Hospital Anxiety and Depression Scale. Results 114 patients completed the study [mean (SD) age 60.48 (10.99) years, FEV 1 108.82% (15.13) predicted, 37 male]. Mean ISWT distance was 690 m (152.68). There were no significant differences in walking distance between males and females (p>0.05). ISWT distance showed significant correlations with age, BMI, FEV 1 , QMVC, DUKE physical activity score and height (p 1 , QMVC and DUKE physical activity score were independent contributors to the ISWT distance achieved by healthy subjects, explaining 50.4% of the variance. (Abstract S120 figure 1). Conclusions Variance in the ISWT can be measured using a composite score, comprising of: age, BMI, FEV 1 , QMVC and DUKE physical activity score. These findings would allow clinicians to express results of the ISWT as a percentage of the predicted values making results more meaningful for patients with chronic conditions.

Introduction & Objectives Few self-management interventions for COPD have conducted qualitative interviews on completion of such a programme and none have followed participant’s longer term. This study conducted interviews with participants allocated to the SPACE FOR COPD self-management programme as part of an RCT. We aimed to gain insight into how the programme was utilised over a 6 month period. Earlier analysis of interviews carried out at 6 weeks highlighted the value of the education material 1 . Method Semi-structured interviews were carried out with participants (n = 24) receiving SPACE for COPD six months after receiving the intervention. Interviews were transcribed verbatim and a constant comparison approach was taken to analysis supported by NVivo software (Version 10) by 2 researchers with experience in qualitative methods. Results Following preliminary analysis, four main themes describe the challenges and conducive behaviours that influenced participant’s self-management behaviours during 6 months of using SPACE FOR COPD - continuing to utilise the manual, establishing an exercise routine, social support & multiple burdens. Many participants describe continuing to use the SPACE FOR COPD manual (e.g. for breathing control techniques and to refresh memory) and establishing an exercise routine early on with the intervention. Social support was utilised for informational (advice), instrumental (help with tasks) and emotional reasons and largely consisted of family members. Challenges to continued regular exercise at home included barriers of time and weather and wider ranging burdens (e.g. other family member’s ill-health, life events, such as moving house). Conclusion Participants reported continued use of the manual and acknowledged thatestablishing a regular exercise routine was instrumental to encouraging continued exercise and this behaviour may have increased feelings of personal control over their disease.However, the challenges identified could disrupt these patterns of self management and further healthcare professional support may be required to help participants cope with these. Participants viewed the telephone support they had had favourably. References L Apps, S Harrison, J Williams, M Steiner, M Morgan & S Singh. (2012). A self-management programme of activity, coping & education (SPACE) for COPD: Patients perspective. ERS Annual Conference 2012

Postoperative pulmonary edema is a well-known postoperative complication caused as a result of numerous etiological factors which can be easily detected by a careful surveillance during postoperative period. However, there are no preoperative and intraoperative criteria which can successfully establish the possibilities for development of postoperative pulmonary edema. The aims were to review the possible etiologic and diagnostic challenges in timely detection of postoperative pulmonary edema and to discuss the various management strategies for prevention of this postoperative complication so as to decrease morbidity and mortality. The various search engines for preparation of this manuscript were used which included Entrez (including Pubmed and Pubmed Central), NIH.gov, Medknow.com, Medscape.com, WebMD.com, Scopus, Science Direct, MedHelp.org, yahoo.com and google.com. Manual search was carried out and various text books and journals of anesthesia and critical care medicine were also searched. From the information gathered, it was observed that postoperative cardiogenic pulmonary edema in patients with serious cardiovascular diseases is most common followed by noncardiogenic pulmonary edema which can be due to fluid overload in the postoperative period or it can be negative pressure pulmonary edema (NPPE). NPPE is an important clinical entity in immediate post-extubation period and occurs due to acute upper airway obstruction and creation of acute negative intrathoracic pressure. NPPE carries a good prognosis if promptly diagnosed and appropriately treated with or without mechanical ventilation.

Objectives Structured physical training programmes are a key component of pulmonary rehabilitation (PR) and have consistently been shown to be of significant benefit to patients with COPD. It is unclear whether the application of similar principles provides similar health improvements in patients with severe asthma. We aimed to assess this by studying the effects of pulmonary rehabilitation in a group of patients with severe asthma and significant disability who have completed our standard 7 week PR programme. Methods 111 patients with a physician diagnosis of severe asthma who have completed our standard PR programme were studied. Assessments including spirometry, chronic respiratory questionnaire (CRQ), hospital anxiety and depression scores (HAD) and incremental and endurance shuttle walk testing (ISWT, ESWT) were performed at baseline and completion to determine the effect of PR. Baseline demographic and spirometric data were compared with a larger population of patients with severe asthma attending our difficult asthma clinic (DAC). Results Following rehabilitation, statistically significant improvements were seen in MRC dyspnoea score (mean (95% CI) improvement −0.35 (−0.13 to −0.57), p=0.003); HADS anxiety (−1.4 (−0.4 to −2.3), p=0.007); HADS depression (−1.2 (−0.2 to −2.2), p=0.026); CRQ dyspnoea (+0.72 (+0.33 to +1.1), p=0.001); CRQ fatigue (+0.92 (+0.65 to +1.2), p 1 % predicted 55.9 vs 71.9, p=0.28) than our DAC population. This may be because clinicians were more likely to refer patients with asthma who had a COPD-like phenotype or because patients with severe asthma were more likely to drop-out of the programme. Conclusion Pulmonary rehabilitation may offer significant benefit to patients with severe asthma though further work is needed to identify the patients mostly likely to benefit and the optimum training required.

Background Patients with difficult-to-treat asthma often have dyspnoea which limits their physical activity. This may lead to progressive deconditioning which may further hamper exercise capacity. We aimed to assess current levels of activity, perceptions of current fitness and interest in a structured exercise programme in patients attending the Glenfield Hospital Difficult Asthma Clinic. Method Patients completed the General Practice Physical Activity Questionnaire which provides a simple Physical Activity Index (PAI) and answered structured questions about their satisfaction with current fitness and their interest in participating in an exercise programme. They were also asked to rate their current fitness compared to peers of the same age on a 100 mm visual analogue score. Responses were compared to demographic details and markers of asthma severity and control. Results Sixty patients participated (37 female, mean (SD) age 53(13)). Only 15/60 (25%) was classified as ‘active’ by the PAI. There were no significant differences in age, gender, body mass index or Juniper asthma control scores between those patients who were active compared to the remaining group but active patients had less severe airflow obstruction (post-bronchodilator FEV 1 83.7(16.5)% predicted vs 68.7(21.8), p=0.04) and better self-reported fitness scores (55.3(27.4) vs 36.7(23.0), p=0.013). There was a statistically significant inverse correlation between fitness scores and Juniper asthma control scores (r = −0.5, p 1 . 65% of patients reported that they had stopped exercising due to their asthma symptoms and 86.7% of patients wanted to be fitter. 71.7% were interested in participating in an exercise programme. Of these 13 (30%) preferred a hospital setting with the remainder preferring a community scheme or an independent programme with support from healthcare professionals. Conclusion Many patients with difficult asthma reported concerns about their current fitness and most were not exercising at the recommended level. There appears to be a demand for the development of a community-based structured exercise programme and further work is needed to determine whether this would improve asthma related outcomes for this group of patients.

Background Physical exercise in healthy individuals leads to an acute inflammatory-cell response in skeletal muscles. In COPD, quadriceps dysfunction is an important systemic manifestation that can be offset by exercise training. However, the nature of the muscle inflammatory response in these patients to acute and chronic exercise remains unknown. We therefore measured inflammatory cell infiltration in the quadriceps of COPD patients and healthy controls, in response to a programme of lower-limb resistance training. Methods 12 COPD patients (mean (SD) age 66.7(7.0) years, BMI 26.1(7.2) kg/m 2 , FEV 1 46.4 (20.5) % predicted, 10 males) and seven healthy controls (66.7 (5.1) years, BMI 27.7(2.4) kg/m 2 , FEV 1 103.4 (17.0) % predicted, five males) underwent 8 weeks of bilateral lower-limb, high-intensity resistance training, thrice weekly, on an isokinetic dynamometer (Cybex II Norm). Quadriceps muscle biopsies from the dominant thigh were obtained at baseline (T0), 24-h after the 1st exercise bout (T1), and 24-h after the last exercise session following 8-weeks training (T2). Glycol methacrylate-embedded muscle biopsies were analysed using immunohistochemistry. Inflammatory cells were identified using antibodies against neutrophil elastase (NE) and CD163 (macrophages). Dual energy x-ray Absorptiometry (DEXA) was used to determine thigh muscle mass and isometric quadriceps strength was measured on the cybex. Results At T0, neutrophils were not detected in any of the healthy controls, but were present in six out of 12 patients. A significant increase in neutrophil and macrophage counts in both patients and controls was seen at T1 (Abstract P142 Table 1). At T2, inflammatory cell counts in both groups were close to baseline values. Isometric quadriceps strength (COPD: pre vs post -134.0 (44.0) vs 151.8 (47.9) Nm, p=0.002; Healthy: pre vs post 153.4 (42.4) vs 169.0 (43.1) Nm, p=0.04] and thigh lean mass (COPD: pre vs post 4.4 (1.2) vs 4.7 (1.2) kg, p=0.003; Healthy: pre vs post 4.5 (0.6) vs 4.7 (0.7) kg, p=0.004] increased significantly after training in both groups. Conclusions Acute resistance exercise in COPD leads to an inflammatory-cell response in the quadriceps that is comparable to healthy controls. Regular training results in muscle adaptation characterised by a diminished inflammatory response to a bout of exercise.