Daniel Neville

Exploring the Waveform Characteristics of Tidal Breathing Carbon Dioxide, Measured Using the N-Tidal C Device in Different Breathing Conditions (The General Breathing Record Study): Protocol for an Observational, Longitudinal Study

Background In an increasingly comorbid population, there are significant challenges to diagnosing the cause of breathlessness, and once diagnosed, considerable difficulty in detecting deterioration early enough to provide effective intervention. The burden of the breathless patient on the health care economy is substantial, with asthma, chronic heart failure, and pneumonia affecting over 6 million people in the United Kingdom alone. Furthermore, these patients often have more than one contributory factor to their breathlessness symptoms, with conditions such as dysfunctional breathing pattern disorders—an under-recognized component. Current methods of diagnosing and monitoring breathless conditions can be extensive and difficult to perform. As a consequence, home monitoring is poorly complied with. In contrast, capnography (the measurement of tidal breath carbon dioxide) is performed during normal breathing. There is a need for a simple, easy-to-use, personal device that can aid in the diagnosis and monitoring of respiratory and cardiac causes of breathlessness. Objective The aim of this study was to explore the use of a new, handheld capnometer (called the N-Tidal C) in different conditions that cause breathlessness. We will study whether the tidal breath carbon dioxide (TBCO2) waveform, as measured by the N-Tidal C, has different characteristics in a range of respiratory and cardiac conditions. Methods We will perform a longitudinal, observational study of the TBCO2 waveform (capnogram) as measured by the N-Tidal C capnometer. Participants with a confirmed diagnosis of asthma, breathing pattern disorders, chronic heart failure, motor neurone disease, pneumonia, as well as volunteers with no history of lung disease will be asked to provide twice daily, 75-second TBCO2 collection via the N-Tidal C device for 6 months duration. The collated capnograms will be correlated with the underlying diagnosis and disease state (stable or exacerbation) to determine if there are different TBCO2 characteristics that can distinguish different respiratory and cardiac causes of breathlessness. Results This study’s recruitment is ongoing. It is anticipated that the results will be available in late 2018. Conclusions The General Breathing Record Study will provide an evaluation of the use of capnography as a diagnostic and home-monitoring tool for various diseases. Registered Report Identifier RR1-10.2196/9767

Using the Inflammacheck Device to Measure the Level of Exhaled Breath Condensate Hydrogen Peroxide in Patients With Asthma and Chronic Obstructive Pulmonary Disease (The EXHALE Pilot Study): Protocol for a Cross-Sectional Feasibility Study

Background Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common conditions that affect over 5 million people in the United Kingdom. These groups of patients suffer significantly from breathlessness and recurrent exacerbations that can be difficult to diagnose and go untreated. A common feature of COPD and asthma is airway inflammation that increases before and during exacerbations. Current methods of assessing airway inflammation can be invasive, difficult to perform, and are often inaccurate. In contrast, measurement of exhaled breath condensate (EBC) hydrogen peroxide (H2O2) is performed during normal tidal breathing and is known to reflect the level of global inflammation in the airways. There is a need for novel tools to diagnose asthma and COPD earlier and to detect increased airway inflammation that precedes an exacerbation. Objective The aim of this study was to explore the use of a new handheld device (called Inflammacheck) in measuring H2O2 levels in EBC. We will study whether it can measure EBC H2O2 levels consistently and whether it can be used to differentiate asthma and COPD from healthy controls. Methods We will perform a cross-sectional, feasibility, pilot study of EBC H2O2 levels, as measured by Inflammacheck, and other markers of disease severity and symptom control in patients with asthma and COPD and volunteers with no history of lung disease. Participants will be asked to provide an exhaled breath sample for measurement of their EBC H2O2 using Inflammacheck. The result will be correlated with disease stage, spirometry, fractional exhaled nitric oxide (FeNO), and symptom control scores. Results This study’s recruitment is ongoing; it is anticipated that the results will be available in 2018. Conclusions The EXhaled Hydrogen peroxide As a marker of Lung diseasE (EXHALE) pilot study will provide an evaluation of a new method of measuring EBC H2O2. It will assess the device’s consistency and ability to distinguish airway inflammation in asthma and COPD compared with healthy controls.

Diagnosis and treatment of severe asthma: a phenotype-based approach

ABSTRACT Severe asthma is a heterogeneous and often difficult to treat condition that results in a disproportionate cost to healthcare systems. Appropriate diagnosis and management of severe asthma is critical, as most asthma deaths have been retrospectively identified as having poorly recognised severe asthma. With multiple biologic agents becoming available, it is crucial to correctly phenotype patients in order to identify those that will respond to these high-cost treatments. We provide an overview of the assessment, phenotyping and management of severe asthma in primary and secondary care.

MISSION COPD: A novel model of integrated multidisciplinary COPD care that demonstrates significant reductions in unscheduled health care usage

Introduction: The MISSION COPD project delivered a one-stop carousel model of integrated COPD care to patients in Wessex in Autumn 2015. Methods: Patients were identified using the GRASP tool. Patients were subdivided in to a “case cohort” where no diagnosis was documented but COPD was suspected, and a “care cohort” where there was a pre-existing diagnosis. Data on healthcare usage for 12 months before the clinic and 6 months after (annualised to 12 months) were used to assess the efficacy of the clinic model. Results: 108 patients were reviewed, with 98 being included in the research project. Complete follow-up data was only available in 91 patients, with 7 having moved out of area by 6 months. Significance in change of unscheduled care usage is described using Wilcoxon signed rank tests. There was a significant reduction in GP visits and exacerbations across both cohorts (p= Conclusions: Unscheduled care usage reduced throughout our cohort after the MISSION COPD review. However, the biggest impact is seen in the reduction in number of exacerbations and GP attendances. The numbers of hospital admissions in the 12 months before the MISSION clinic were low in this cohort, but it is noteworthy that one ED visit costs almost twice an unscheduled GP visit, so fewer reductions are needed to lead to a saving to the health economy. The MISSION model targets patients at greatest risk of harm from disease, improving outcomes and saving money for the health system.

The use of the Nijmegen Questionnaire in assessment of breathing pattern disorders in COPD

Introduction: Breathing pattern disorders (BPD) contribute to breathlessness in respiratory disease. The Nijmegen Questionnaire (NQ) is used as a screening tool for BPD with a score >23 suggesting functional respiratory complaints and the accuracy of the NQ in COPD is unknown. We compared the predictive value of the NQ to clinical assessment and describe our findings of the prevalence of BPD in COPD. Methods: Patients with poorly controlled COPD were identified in a community respiratory clinic and evaluated for disease control and comorbidities. Screening for BPD was conducted by the NQ and examination by a specialist physiotherapist. Results: 25 of 53 patients (43%) were identified as having BPD by both clinical evaluation and a NQ score >23. There were no patients with a NQ score >23 without BPD confirmed by clinical assessment. The mean NQ scores in those with and without clinically confirmed BPD were 31 (Range 18-45, SD ±8) and 14 (Range 2-22, SD ±7, p value = 23 gave positive and negative predictive values of 100% and 92% respectively for detecting BPD. BPD were present throughout the spectrum of COPD severity, though more prevalent in those with moderate disease was not statistically significant (ANOVA analyses p=0.71). Conclusion: BPD are a common comorbidity in highly symptomatic COPD and may be more prevalent in moderate COPD. The use of a NQ score of >23 may be a useful tool in screening for BPD in COPD and compares favourably with clinical evaluation. Screening for BPD should be part of assessment of patients with highly symptomatic COPD; the recognition of which gives alternative treatment options in COPD.

Asthma attendances in the emergency department; frequency and timing

Introduction: Acute exacerbations cause major disruption to the lives of those suffering with asthma. Frequent admissions have a significant impact on healthcare resources. Timing of attendance is relevant for healthcare planning and the appropriate treatment of people with asthma. Objective: To determine the timing and frequency of attendances due to asthma to our large district general emergency department over the course of a calendar year. Methods: Hospital attendance records were used to record every attendance to ED between 01/01/15 to 31/12/15 due to asthma at our centre. This was used to ascertain the rate of attendance and variation with time, day and month. Chi-squared tests were used to compare attendance to average expected values. Results: There were 693 attendances to our Emergency Department in 2015 due to asthma, comprising 546 different patients. 50.8% of patients were admitted from the ED. 75 patients had 2 or more attendances, while 38 patients were admitted 2 or more times. Attendance was highest on Sunday and Monday, lowest on Thursday and Friday and this was statistically significant (p=0.001), but admission rates did not differ significantly (p=0.99). Attendances were significantly (p=0.02) higher in October and November (n=73-74) than in April to August (n=48-52). Attendance peaked at 6-7pm and 10-11pm, but was lowest between midnight and 8am. Conclusions: Asthma attendances at our centre were significantly higher on Sunday and Monday, in October and November and during the evenings. This analysis is important for ED and asthma workforce planning and education. We plan to target the most frequent attenders to our service in an attempt to reduce our attendance rates.