F.H.C. de Jongh

What the pulmonary specialist should know about the new inhalation therapies

A collaboration of multidisciplinary experts on the delivery of pharmaceutical aerosols was facilitated by the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM), in order to draw up a consensus statement with clear, up-to-date recommendations that enable the pulmonary physician to choose the type of aerosol delivery device that is most suitable for their patient. The focus of the consensus statement is the patient-use aspect of the aerosol delivery devices that are currently available. The subject was divided into different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. To achieve consensus, draft reports and recommendations were reviewed and voted on by the entire panel. Specific recommendations for use of the devices can be found throughout the statement. Healthcare providers should ensure that their patients can and will use these devices correctly. This requires that the clinician: is aware of the devices that are currently available to deliver the prescribed drugs; knows the various techniques that are appropriate for each device; is able to evaluate the patients inhalation technique to be sure they are using the devices properly; and ensures that the inhalation method is appropriate for each patient.

Pneumothorax in a preterm infant monitored by electrical impedance tomography: a case report.

Electrical impedance tomography (EIT) is a noninvasive bedside tool for monitoring regional changes in ventilation. We report, for the first time, the EIT images of a ventilated preterm infant with a unilateral pneumothorax, showing a loss of regional ventilation in the affected lung during both high-frequency oscillation and spontaneous ventilation.

Effects of a single dose inhaled corticosteroid on the dynamics of airway obstruction after exercise

Exercise‐induced bronchoconstriction (EIB) is defined as a transient narrowing of the airways induced by exercise. Repetitive measurements of spirometric parameters, such as FEV1 and expiratory flows, and forced oscillation technique (FOT) measurements can be used to analyze the dynamics of EIB. A single high dose of fluticasone propionate (FP) protects against EIB. The aim of the study was to analyze the effect of FP on the dynamics of exercise‐induced airway narrowing as measured with FOT and spirometry.

Electrical activity of the diaphragm during nCPAP and high flow nasal cannula

Objective To determine if the electrical activity of the diaphragm, as measure of neural respiratory drive and breathing effort, changes over time in preterm infants transitioned from nasal continuous positive airway pressure (nCPAP) to high flow nasal cannula (HFNC). Design Prospective observational study. Setting Neonatal intensive care unit. Patients Stable preterm infants transitioned from nCPAP to HFNC using a 1:1 pressure to flow ratio. Interventions The electrical activity of the diaphragm was measured by transcutaneous electromyography (dEMG) from 30 min before until 3 hours after the transition. Main outcome measures At eight time points after the transition to HFNC, diaphragmatic activity was compared with the baseline on nCPAP. Percentage change in amplitudedEMG, peakdEMG and tonicdEMG were calculated. Furthermore, changes in respiratory rate, heart rate and fraction of inspired oxygen (FiO2) were analysed. Results Thirty-two preterm infants (mean gestational age: 28.1±2.2 weeks, mean birth weight: 1118±368 g) were included. Compared with nCPAP, the electrical activity of the diaphragm did not change during the first 3 hours on HFNC (median (IQR) change in amplitudedEMG at t=180 min: 2.81% (−21.51–14.10)). The respiratory rate, heart rate and FiO2 remained stable during the 3-hour measurement. Conclusions Neural respiratory drive and breathing effort assessed by electrical activity of the diaphragm is similar in the first 3 hours after transitioning stable preterm infants from nCPAP to HFNC with a 1:1 pressure-to-flow ratio.

Multi-centre prospective study on diagnosing subtypes of lung cancer by exhaled-breath analysis

OBJECTIVES Lung cancer is a leading cause of mortality. Exhaled-breath analysis of volatile organic compounds (VOCs) might detect lung cancer early in the course of the disease, which may improve outcomes. Subtyping lung cancers could be helpful in further clinical decisions. MATERIALS AND METHODS In a prospective, multi-centre study, using 10 electronic nose devices, 144 subjects diagnosed with NSCLC and 146 healthy subjects, including subjects considered negative for NSCLC after investigation, breathed into the Aeonose™ (The eNose Company, Zutphen, Netherlands). Also, analyses into subtypes of NSCLC, such as adenocarcinoma (AC) and squamous cell carcinoma (SCC), and analyses of patients with small cell lung cancer (SCLC) were performed. RESULTS Choosing a cut-off point to predominantly rule out cancer resulted for NSCLC in a sensitivity of 94.4%, a specificity of 32.9%, a positive predictive value of 58.1%, a negative predictive value (NPV) of 85.7%, and an area under the curve (AUC) of 0.76. For AC sensitivity, PPV, NPV, and AUC were 81.5%, 56.4%, 79.5%, and 0.74, respectively, while for SCC these numbers were 80.8%, 45.7%, 93.0%, and 0.77, respectively. SCLC could be ruled out with a sensitivity of 88.9% and an NPV of 96.8% with an AUC of 0.86. CONCLUSION Electronic nose technology with the Aeonose™ can play an important role in rapidly excluding lung cancer due to the high negative predictive value for various, but not all types of lung cancer. Patients showing positive breath tests should still be subjected to further diagnostic testing.

ERS Technical Standard on Bronchial Challenge Testing: Pathophysiology and Methodology of Indirect Airway Challenge Testing

Recently, this international task force reported the general considerations for bronchial challenge testing and the performance of the methacholine challenge test, a “direct” airway challenge test. Here, the task force provides an updated description of the pathophysiology and the methods to conduct indirect challenge tests. Because indirect challenge tests trigger airway narrowing through the activation of endogenous pathways that are involved in asthma, indirect challenge tests tend to be specific for asthma and reveal much about the biology of asthma, but may be less sensitive than direct tests for the detection of airway hyperresponsiveness. We provide recommendations for the conduct and interpretation of hyperpnoea challenge tests such as dry air exercise challenge and eucapnic voluntary hyperpnoea that provide a single strong stimulus for airway narrowing. This technical standard expands the recommendations to additional indirect tests such as hypertonic saline, mannitol and adenosine challenge that are incremental tests, but still retain characteristics of other indirect challenges. Assessment of airway hyperresponsiveness, with direct and indirect tests, are valuable tools to understand and to monitor airway function and to characterise the underlying asthma phenotype to guide therapy. The tests should be interpreted within the context of the clinical features of asthma. This international task force recently reported the general considerations for “direct” bronchoprovocation testing. In the present document, the task force provides updated recommendations on the pathophysiology and conduct of “indirect” challenge tests. http://ow.ly/FR1K30m99Ef

Using exhaled breath profiles in the discrimination between COPD, lung cancer and their co-morbidity

Rationale: Lung cancer, a major cause of morbidity and mortality throughout the world, is also a frequent comorbidity in COPD. When using exhaled breath profiles by electronic nose in the discrimination between COPD and lung cancer the data have shown definite overlap (Dragonieri Lung Canc. 2009). Aim: To determine diagnostic accuracy of exhaled breath analysis by SpiroNose for COPD vs. lung cancer and to identify those patients who, based on exhaled breath profiles, are allocated in the overlap area between both diseases. Methods: This was a cross-sectional study on outpatients with standardized diagnosis of COPD and/or lung cancer. During spirometry, fingerprints from exhaled breath were collected in triplicate by an eNose based on 3 identical sensor arrays at the rear end of a pneumotach. Data-analysis involved signal processing, environment correction and statistics based on principal component analysis, followed by discriminant analysis (Matlab2014). Results: Exhaled breath data of 29 lung cancer (age 63±9.5yr) and 30 COPD (age 66±8.4) patients were available. Principal component 1 (p Conclusion: Exhaled breath analysis by SpiroNose is able to discriminate between COPD and lung cancer. Patients with a double diagnosis are correctly allocated in the overlap area. However, the diagnosis of lung cancer is not unambiguous in patients with comorbid COPD, highlighting the need for optimizing the sensor arrays.

O-218 The Effect Of Caffeine On Diaphragmatic Activity In Preterm Infants

Background Preterm infants born with a GA <32 weeks are at high risk of developing central apnea of prematurity (AOP). Treatment with caffeine reduces central AOP by stimulating the breathing centre. Animal studies suggest that caffeine improves contractility of the diaphragm. We have determined the effect of caffeine on diaphragmatic activity in preterm infants. Methods Spontaneously breathing preterm infants <32 weeks treated with an intravenous loading dose (10 mg/kg) of caffeine base for central AOP were eligible for the study. Diaphragmatic activity was continuously measured by transcutaneous electromyography (dEMG) starting 30-min before (baseline) until 1-hour after caffeine administration. Diaphragmatic inspiratory activity per breath, expressed as the relative amplitude change of dEMG (logEMGAR), area under the curve (AUC), respiratory rate (RR), as well as tidal volume (Vt ) measured by respiratory inductive plethysmography, were calculated at 4 fixed time points after caffeine administration (5,15,30 and 60-min) using the average of all breaths in a 30-sec recording and compared to baseline. Results 30 preterm infants (mean GA 29.1 ± 1.3 wk; birth weight 1237 ± 370 g) were included. 5-min after caffeine administration, diaphragmatic activity significantly increased (median, IQR) compared to baseline; logEMGAR (0.13, 0.09–0.17), corresponding with an amplitude increase of 35% (22–49%). AUC (19%, 11–34%) and Vt (30%, 7–48) also increased significantly. Caffeine did not impact RR. The increased activity was observed at all subsequent time points. Conclusions This is the first study showing that caffeine treatment, besides stimulating respiratory drive, results in a rapid (within 5-min) and sustained increase in diaphragmatic contractility in preterm infants.

Can deceiving COPD smokers be detected by measuring exhaled CO to determine smoking status? A validation of three Co monitors

In alphabetical order by first author Validation of short-form scales for measuring depression in health-survey context *Aalto, A.-M., Kivimäki, M., Pirkola, S.; *Stakes (National Research and Development Centre for Welfare and Health), Helsinki, Finland Depression is highly relevant and associated with various physical illnesses. Therefore a valid measure of depression in health-related surveys is well-grounded. However, conventional measures of depression such as BDI21, are often burdensome for respondents in extensive surveys. This study examines validity and usability of short-form measures of depression in a survey context. Methods The data (n1⁄4 6005) was derived from the Finnish population based ‘‘Health 2000’’ – study, which included questionnaires and health examination. The scales under validation were BDI13, GHQ12 and GHQ12 depression & anxiety subscale (GHQad; Graez, 1991). The criterions for convergent-discriminant validity were BDI21 and CIDI-diagnosis (depressive or anxiety disorder). Also other psychometric properties as well as sociodemographic, personality and health-related correlates of depression scales were examined. Results The Cronbach alpha was highest for GHQ12 (0.90) and lowest for GHQad (0.79). Correlations with BDI21 were: 0.96 (BDI13), 0.69 (GHQ12) and 0.59 (GHQad). Depressive disorder explained clearly more of variance in all scales than anxiety disorder, though this pattern was less clear among women. Sociodemographic differences (age, gender & education) were found mainly in BDI scales. Correlations of BDI21, BDI13, GHQ12 and GHQad with cynical hostility were 0.31, 0.31, 0.18 and 0.19, with handicapping chronic illness 0.40, 0.34, 0.28 and 0.22, and with use of mental health services 0.26, 0.26, 0.22 and 0.21 respectively. Conclusions All scales showed acceptable reliability and convergent – discriminant validity in terms of CIDI classification, but the sociodemographic patterning of GHQ12 scores differed from that of BDI scales. Particularly the 13-item version of BDI seems to perform equally well as the longer form and can be recommended as an alternative to questionnaire surveys. Sequencing and prioritising of intentions in planned behaviour Abraham, C.; University of Sussex, UK Objectives This paper will demonstrate that social cognition models can be enhanced by looking beyond single intentions to the multiple, conflicting, congruent and interdependent intentions from which planned behaviour emerges. Method and Results Results from a number of surveys will be presented demonstrating that consideration of multiple intentions can enhance the predictive utility of the theory of planned ISSN 0887-0446 print/ISSN 1476-8321 online 2005 Taylor & Francis Group Ltd DOI: 10.1080/14768320500221275 behaviour and help clarify the nature of intention–behaviour discrepancies. Many health behaviours (e.g., studying or using a condom) involve sequences of actions so that the strength of a behavioural intention depends on the establishment of intentions to undertake prerequisite actions. For example, in a cross sectional survey of 2120 Scottish 16 year olds, after controlling for TPB predictors, measures of preparatory intentions (e.g., the intention to suggest condom use to a sexual partner) added 10% to the variance explained in the intention to always use condoms. Moreover, the strength of conflicting intentions may moderate intention-behaviour relationships. For example, in a survey of 419 students who had intended to use a condom during their last sexual intercourse with a new partner, the relative importance of having sex versus using a condom during sex discriminated most effectively between those who had and had not used a condom on that occasion. Finally, results form intervention evaluations focusing on physical activity will be reviewed, demonstrating the efficacy of goal setting as a behavioural intervention technique. Conclusion Predictive models should assess congruent, competing and prerequisite intentions as well as behavioural intentions matched to target behaviours. Simple explanations increase comprehension of terms used in oncology consultations *Abraham, C., Dudley, J.; *University of Sussex, UK Objectives To assess and enhance understanding of terms used in oncology consultations reported to be difficult to understand by patients. Methods Two street surveys were conducted. In the first survey phrases and terms were presented as recorded in consultations. In the second short, simple explanatory phrases were added to statements used in the consultations. Identical comprehension assessments were employed. Results In line with previous findings, the first survey (N1⁄4 101) demonstrated that understanding of terms and phrases used to describe cancer screening, diagnoses, prognoses, and treatment is poor. For example, less than 40% of participants understood terms such as: ‘‘spots within the liver’’, ‘‘seedlings’’ and ‘‘in remission’’. Even common terms were not understood by all with 30% of respondents failing to understanding that ‘‘metastasise’’ meant spreading of cancer. There were no significant demographic differences between the first and second survey samples (N1⁄4 101). Both samples were recruited in the same manner. In survey two simple explanations were added to oncologists original statements. For example, in the case of ‘‘spots within the liver’’, the explanation ‘‘This means that you have cancer in your liver’’ was added. These additions improved comprehension so that the same statements referring to ‘‘spots within the liver’’, ‘‘seedlings’’, ‘‘in remission’’ and ‘‘metastasise’’ were understood correctly by 93, 83, 73 and 98%, respectively. Conclusions Simple clarifications which would take only seconds to add to a consultation can substantially alter the proportion of lay people who understand statements made in oncology consultations. Changes in HAPA–model constructs predict type 2 diabetes risk factor reduction in life-style counselling *Absetz, P., Heinonen, H., Valve, R., Talja, M., Uutela, A, Nissinen, A., Fogelholm, M.; *National Public Health Institute, Finland Objective To study clinical risk factor changes among participants of a theoryand evidence-based life-style counselling program, and the effect of social-cognitive predictors on the change. Methods Subjects were Finnish men (N1⁄4 102) and women (N1⁄4 286, age 50–65) at an increased risk for type 2 diabetes recruited from primary care centres to participate in the GOAL life-style 10 Abstracts426 students aged 17–22 (m=18) completed a questionnaire, based on Ajzens Theory of Planned Behavior and its following developments, designed to study the determinants leading to accept a lift from a drunk driver. The data have been subjected to multiple regression Discussion Social norms (p <.05) and particularly peers norms (p<.001) seem to significatively predict the intention to get into a car with a drunk friend. Also perceived behavior control (p <.001) and risk perception (p<.01) seem to motivate the intentions. In licensed young adults also self-esteem (p <.01) influences intentions. The To Drink and to Drive: The Passengers PerspectiveSocial cognitive techniques work on both the task-oriented and emotion-oriented level focusing on enhancement of perceived capability, creating a role model environment and opportunities for mastery experience. There is no analysis system that addresses implementation of selfefficacy oriented interventions. To fill in the gap an analysis system for the coding of selfefficacy related interventions in training programs (ASSET: Analysis System for Self-Efficacy Training) has been developed. Four super categories have been deductively derived from Social Cognitive Theory: Mastery Experience, Role Model, Verbal Persuasion, and Physical and Affective State (Bandura, 1997). In the next step, the materials from self-management program manuals (DESMOND, 2004; Lorig, 1996) were used to inductively identify particular interventions as subcategories. Finally, the subcategories have been extended and refined on the basis of observation of self-management education programs run in local health care services. In the next step, ASSET will be validated. Participants’ behavioural, cognitive and emotional change, derived from self-report questionnaires, will be related to the frequency of utilized self-efficacy enhancing strategies. Having considered the high predictability of self-efficacy belief on behaviour change, it is expected that programs with high numbers of utilized selfefficacy oriented interventions will result in better illness adjustment. The validation study results will be presented in this poster.