Laurie Smith

STAAR: a randomised controlled trial of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for children with asthma

Background Suboptimal adherence to inhaled steroids is common in children with asthma and is associated with poor disease control, reduced quality of life and even death. Previous studies using feedback of electronically monitored adherence data have demonstrated improved adherence, but have not demonstrated a significant impact on clinical outcomes. The aim of this study was to determine whether introduction of this approach into routine practice would result in improved clinical outcomes. Methods Children with asthma aged 6–16u2005years were randomised to the active intervention consisting of electronic adherence monitoring with daily reminder alarms together with feedback in the clinic regarding their inhaled corticosteroid (ICS) use or to the usual care arm with adherence monitoring alone. All children had poorly controlled asthma at baseline, taking ICS and long-acting β-agonists. Subjects were seen in routine clinics every 3u2005months for 1u2005year. The primary outcome was the Asthma Control Questionnaire (ACQ) score. Secondary outcomes included adherence and markers of asthma morbidity. Results 77 of 90 children completed the study (39 interventions, 38 controls). Adherence in the intervention group was 70% vs 49% in the control group (p≤0.001). There was no significant difference in the change in ACQ, but children in the intervention group required significantly fewer courses of oral steroids (p=0.008) and fewer hospital admissions (p≤0.001). Conclusions The results indicate that electronic adherence monitoring with feedback is likely to be of significant benefit in the routine management of poorly controlled asthmatic subjects. Trial registration number NCT02451709; pre-result.

Detection of early sub-clinical lung disease in children with cystic fibrosis by lung ventilation imaging with hyperpolarized gas MRI

Hyperpolarised 3He ventilation-MRI, anatomical lung MRI, lung clearance index (LCI), low-dose CT and spirometry were performed on 19 children (6–16u2005years) with clinically stable mild cystic fibrosis (CF) (FEV1>−1.96), and 10 controls. All controls had normal spirometry, MRI and LCI. Ventilation-MRI was the most sensitive method of detecting abnormalities, present in 89% of patients with CF, compared with CT abnormalities in 68%, LCI 47% and conventional MRI 22%. Ventilation defects were present in the absence of CT abnormalities and in patients with normal physiology, including LCI. Ventilation-MRI is thus feasible in young children, highly sensitive and provides additional information about lung structure–function relationships.

Longitudinal Assessment of Children with Mild CF Using Hyperpolarised Gas Lung MRI and LCI

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Supine posture changes lung volumes and increases ventilation heterogeneity in cystic fibrosis

Introduction Lung Clearance Index (LCI) is recognised as an early marker of cystic fibrosis (CF) lung disease. The effect of posture on LCI however is important when considering longitudinal measurements from infancy and when comparing LCI to imaging studies. Methods 35 children with CF and 28 healthy controls (HC) were assessed. Multiple breath washout (MBW) was performed both sitting and supine in triplicate and analysed for LCI, Scond, Sacin, and lung volumes. These values were also corrected for the Fowler dead-space to create ‘alveolar’ indices. Results From sitting to supine there was a significant increase in LCI and a significant decrease in FRC for both CF and HC (p<0.01). LCI, when adjusted to estimate ‘alveolar’ LCI (LCIalv), increased the magnitude of change with posture for both LCIalv and FRCalv in both groups, with a greater effect of change in lung volume in HC compared with children with CF. The % change in LCIalv for all subjects correlated significantly with lung volume % changes, most notably tidal volume/functional residual capacity (Vtalv/FRCalv (r = 0.54,p<0.001)). Conclusion There is a significant increase in LCI from sitting to supine, which we believe to be in part due to changes in lung volume and also increasing ventilation heterogeneity related to posture. This may have implications in longitudinal measurements from infancy to older childhood and for studies comparing supine imaging methods to LCI.

P283 Hyperpolarised Gas MRI – a pathway to Clinical Diagnostic Imaging

Introduction Despite the excellent functional sensitivity of hyperpolarised gas MRI to early lung disease, clinical uptake of the technique has to date been hindered by patents, regulatory classification, availability of 3He and access to polariser technology. However, many of these constraints have been alleviated in recent years, and 129Xe MRI is now providing high quality lung images at relatively low cost. In January 2015 UK regulatory approval for the manufacture of hyperpolarised gases for routine clinical lung imaging was obtained in Sheffield. Here we present a case series as an overview of the clinical questions that this technology can help resolve in various respiratory indications. Methods More than 20 patients (aged 13 to 74) have been clinically referred to date with HP gas MRI in Sheffield to date from NHS hospitals across the UK. Clinical histories include non-CF bronchiectasis (scanned before and after a 2 week course of IV antibiotics), COPD for consideration for LVRS/EB valves, complex asthma (scanned before and after bronchodilator inhalation), CF, patients with poor gas transfer but well-preserved lung parenchyma on CT, IPF overlapping with emphysema. Results Figure 1 shows example images from a cross-section of patients scanned, details of the individual cases will be expanded upon. No adverse events related to imaging were reported. In terms of imaging workflow, scan time average was between 30 min and 1 h 30 min. Patients have been referred from clinics within a 100 km radius and we are also active in enabling novice sites further afield with the technology.Abstract P283 Figure 1 Example of 3He ventilation images; non-CF bronchiectasis patient (a) before and (b) after IV anti biotics, asthma patient (c) before and (d) after bronchodilator, (e) CF patient, and (f) COPD patient I a 129Xe ventilation image (g) COPD patient 2, and a 1H perfusion image (h) patient with poor gas transfer Conclusion Hyperpolarised gas MR provides sensitive, regional images of lung function which can be used to aid in clinical decision making on an individual patient basis. With improvements in gas polarisation, MR hardware and image acquisition techniques routine clinical lung imaging with the cheaper gas isotope 129Xe is also now possible and large scale clinical evaluation of these methods in patient populations are now underway as part of clinical work up.

Patterns of regional lung physiology in cystic fibrosis using ventilation MRI and MBW

Hyperpolarised helium-3 (3He) ventilation magnetic resonance imaging (MRI) and multiple-breath washout (MBW) are sensitive methods for detecting lung disease in cystic fibrosis (CF). We aimed to explore their relationship across a broad range of CF disease severity and patient age, as well as assess the effect of inhaled lung volume on ventilation distribution. 32 children and adults with CF underwent MBW and 3He-MRI at a lung volume of end-inspiratory tidal volume (EIVT). In addition, 28 patients performed 3He-MRI at total lung capacity. 3He-MRI scans were quantitatively analysed for ventilation defect percentage (VDP), ventilation heterogeneity index (VHI) and the number and size of individual contiguous ventilation defects. From MBW, the lung clearance index, convection-dependent ventilation heterogeneity (Scond) and convection–diffusion-dependent ventilation heterogeneity (Sacin) were calculated. VDP and VHI at EIVT strongly correlated with lung clearance index (r=0.89 and r=0.88, respectively), Sacin (r=0.84 and r=0.82, respectively) and forced expiratory volume in 1u2005s (FEV1) (r=−0.79 and r=−0.78, respectively). Two distinct 3He-MRI patterns were highlighted: patients with abnormal FEV1 had significantly (p<0.001) larger, but fewer, contiguous defects than those with normal FEV1, who tended to have numerous small volume defects. These two MRI patterns were delineated by a VDP of ∼10%. At total lung capacity, when compared to EIVT, VDP and VHI reduced in all subjects (p<0.001), demonstrating improved ventilation distribution and regions of volume-reversible and nonreversible ventilation abnormalities. Ventilation distribution on MRI improves at TLC and two distinct patterns of regional lung disease in CF are highlighted, where abnormal FEV1 is associated with VDP >10%. Ventilation MRI and MBW are highly correlated. http://ow.ly/NvyS30lOP4O