TSANZ Ann Woolcock Young Investigator Awards Oral

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Respirology (2016) 21 (Suppl. 2), 21–100 doi: 10.1111/resp.12754

TO 002 Nurses SIG Symposium Part 1 Oral Presentations

NURSES SUPPORT DELIVERY OF SPIROMETRY TO TOP END RESPIRATORY OUTREACH CLINICS: A REVIEW OF THE TO 001 SERVICE EXPANSION AND DEVELOPMENT OF SYSTEMS

HARWOOD S, O’LOUGHLAN M Royal Darwin Hospital INCIDENCE AND OUTCOMES OF ACUTE RESPIRATORY ILLNESS (ARI) WITH COUGH IN URBAN INDIGENOUS CHILDREN Introduction/Aim: Chronic lung conditions are a major cause of morbidity and mortality among Indigenous Australians in remote communities across HALL K1, CHANG A1,2,3,ANDERSONJ4, ARNOLD D1, KEMP A4,O’GRADY K1 the Northern Territory (NT) Top End. The Royal Darwin Hospital (RDH) respi- 1Queensland University of Technology, 2Menzies School of Health Research, ratory service commenced on site in 2010 and identified a lack of spirometry Charles Darwin University, Darwin, 3Department of Respiratory Medicine, testing at remote community health clinics. Remote outreach clinic planning Queensland Children’s Health Services, Brisbane, 4Murri Health Group, prioritized the provision of nurse led spirometry testing so essential for access Caboolture to early detection, diagnosis and monitoring of chronic lung conditions. We performed a review of the service to monitor the expansion including spirometry numbers and systems used for the performance and recording of spirom- Introduction: Studies suggest that 10% of children with an ARI have etry tests obtained from a cohort of 408 clients from 21 remote clinics. persistent cough at day 21. There are no studies in Indigenous children who Methods: have a high risk of chronic lung disease. We aimed to identify the incidence • We performed a retrospective review of spirometry numbers from 21 and outcomes of ARI with cough as a symptom in urban Indigenous children. remote clinics from 2013 to 2015. Methods: This is a prospective study of Indigenous children aged <5years • We reviewed the current service and the relevant literature, and we registered with a primary health service. Children are followed for a period of consulted with the Alfred Hospital Lung Testing Laboratory to examine their 12 months via monthly contacts. Children who develop cough as a symptom systems. at any time are followed weekly for 4 weeks to ascertain cough outcomes. • We analysed the current systems used to record the spirometry data in the Results: To date, 162 children are enrolled, totalling 1065 child-months of health information systems. observation. Two-hundred ARI episodes with cough have been reported (29.6 Results: episodes/100 child-months at risk). Thirty-four ARIs (17%) have progressed to 1 Numbers expanded from 66 spirometry tests performed in 21 remote persistent cough at day 28 in 24 children. Of these, 15 children had 1 episode, clinics in 2013, 210 in 2014 and 132 in 2015; data collection is ongoing. 5had2,4had3and1had4duringthefollow-upperiod.Themajorityof 2 We developed a unit quality assurance programme and a remote spirome- children with persistent cough were diagnosed (by a respiratory physician) try policy and procedure to provide quality and standardized tests. with protracted bacterial bronchitis and/or bronchiectasis. 3 In 2013, 66 spirometry test results were shared with other health profes- Conclusions: The proportion of children developing persistent cough post- sionals only in respiratory physician letters. In 2014, 210 spirometry tests were ARI is higher than that currently reported (10%) with the majority suggesting also shared into the remote electronic information systems. In 2015, 132 spi- protracted bacterial infection. rometry tests were also shared in the (RDH) acute information system and re- Grant Support: A QUT APA award, a QCMRI Program Grant, UQ Founda- ported on by our respiratory physicians. tion Research Excellence Award, a QUT Indigenous Health Research Start- Conclusions: The expansion of the (RDH) respiratory service improved Up Grant and the NHMRC CRE for Lung Health in Aboriginal and Torres Strait access to quality spirometry testing for those with chronic lung conditions in re- Islander Children. mote Top End clinics. Spirometry data are shared with health professionals Declaration of Interest: None to Declare across the remote and acute health settings of the (NT) Top End. Further innovative methods are now required to provide both access and shared spirometry information across health settings. Grant Support: None, nothing to declare.

TO 003 Nurses SIG Symposium Part 2 Oral Presentations

ESTABLISHING CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) COMPLIANCE AMONG THE SOCIO-ECONOMICALLY DEPRIVED SOUTH AUCKLAND POPULATION BY INTRODUCTION OF COMMUNITY BASED NURSE-LED TO 004 CLINICS AND WALK-IN CLINICS

KARUMALIL J, HERATH S AN EVALUATION OF OUTREACH RESPIRATORY NURSING Middlemore Hospital, Auckland, New Zealand PRACTICE FOR THE MANAGEMENT OF COPD COMPARED TO NURSING BEST PRACTICE GUIDELINES: OBSERVATIONAL COHORT STUDY OF CHANGES OVER TIME Introduction/Aim: Patient compliance is the key to successful CPAP therapy. The lower socioeconomic status and dominance of non-European eth- 1,2,3 1,2,3 1,2,3 1,2,3 1,2,3 nicity with higher prevalence of obstructive sleep apnoea (OSA) in our ROYALS K ,LAWTONK , KOPSAFTIS Z , CARSON K ,SMITHB 1The Queen Elizabeth Hospital, South Australia, 2Clinical Practice Unit, Basil patients pose a marked hindrance to CPAP compliance. 3 This 6-month quality control audit (from July 2013) aims to measure CPAP Hetzel Institute for Translational Health Research, South Australia, School of compliance in the above group, following introduction of community-based, Medicine, The University of Adelaide, South Australia nurse-led clinics and walk-in clinics. Methods: In order to provide a CPAP device, all patients had auto set pres- Introduction/Aim: Respiratory nursing best practice guidelines for COPD sure determination following the diagnosis of OSA, facilitated by sleep nurses, were released in 2005 by the Registered Nurses Association of Ontario. An 6-weeks post-treatment compliance is assessed in the sleep nurse clinic. audit of patients attending the Respiratory Nursing Service (RNS) at The Patients had the facility to come to a walk-in clinic, staffed by community Queen Elizabeth Hospital (TQEH), Adelaide, South Australia in 2006 revealed healthcare workers; supervised by a sleep nurse specialist, 5 days of the poor compliance to these guidelines. Therefore, the aim of this study was to week without appointments, for troubleshooting. determine if compliance to these best practice guidelines had improved for Results: Of the 3782 patients currently on CPAP, 123 were audited during COPD patients in the Respiratory Nursing Service. this period. Seventy-three percent (n = 91) were male. Mean age was Methods: A 12-month retrospective observational cohort study was con- 51 years. (range 21–79 years). Mean AHI 36.4/h. Majority were non-European ducted through review of medical records, internal respiratory databases (67%) (Table 1). and electronic patient record systems. All new patients admitted to the RNS In the total group, 60% (n = 74) had CPAP usage of >4 h, demonstrating at TQEH with a diagnosis of COPD in 2013 were included. Data were a marked success in this group, as >4 h compliance is not achieved by extracted into a standardized pilot-tested template and were analysed using 46–83%. In our group, only n = 31 (25%) did not have >4 h compliance. Microsoft Excel 2010. The most compliant are NZ European n = 30/41 (73%) and least compliance Results: Thirty-eight patients were included in the audit. By 2013, the in Samoan n = 9/20 (45%) (Table 1). guideline recommendations which had poor compliance in 2006 showed In keeping with published standards, 14.5% (n = 18) failed to continue to use marked improvement, and the % change for these included: referral offered the CPAP in 1–5months. to pulmonary rehabilitation (59%), use of qualitative tool for dyspnoea assess- Conclusion: Despite socio-economic barriers, we have achieved excep- ment (63%), nutritional status (66%), discussions on advanced care planning tional CPAP compliance exceeding the published rates and kept the refusal (53%), smoking cessation strategies (76.5%) and sputum clearance (70.2%). at accepted levels, whilst using home auto set titration as the initial pressure Full compliance to the guidelines was documented for assessment of hypoxia determination mode. and review of oxygen flow rates for patients with oxygen therapy. Areas still We believe this success is due to nurse-led clinics and community walk-in found to have poor compliance overall with the guideline include checking of clinics that cater to the needs of the patient by providing patient education inhaler technique (50%) and completion of a COPD action plan (26%). and support outside the hospital setting. Conclusions: Guideline compliance has improved within the Respiratory Grant Support: none Nursing Service over time. Variances between staff documentation practices may account for slower improvement in some areas. However, time con- Table 1. CPAP compliance (by ethnicity and number of hours used) when straints, patient refusal and a lack of applicability to some guidelines may also measured at 6 weeks post-commencement, following in home auto set pres- be a factor contributing to poor compliance. This suggests that a revision of the sure determination in the socio-economically deprived South Auckland 2005 guideline may be needed to ensure relevance to current practices. population Grant Support: Nil. Conflict of Interest: None. NZ European Maori Samoan Indian Chinese Tongan Other Total

Compliance 30 13 8 6 3 4 10 74 above 4 h (60%) Compliance 311934 1031 below 4 h (25%) Refused 8 2 3 1 2 1 1 18 (14%) Numbers in 41 26 20 10 9 6 11 123 total (33%) (21%) (16%) (8%) (7%) (5%) (9%) (100%)

TO 005 TO 006

ASTHMA SELF-MANAGEMENT EDUCATION AND INHALED NURSE LED SLEEP ASSESSMENTS IN A SMALL NZ DHB CORTICOSTEROID USE DURING PREGNANCY AND POSTPARTUM FROM 2004 TO 2014 BOX D South Canterbury DHB STEEL K1,2,GIBSONP1,2,MURPHYV1 1 2 University of Newcastle, John Hunter Hospital Newcastle Introduction/Aim: Regional service delivery for specialist sleep care is challenging in a resource-limited environment. Before 2014, the South Canter- Introduction/Aim: Asthma exacerbations and medication non-adherence bury District Health District (DHB) (population 55 000) had no established re- are significant clinical problems during pregnancy. Provision of self-manage- ferral pathway for patients with suspected obstructive sleep apnoea (OSA). ment education is effective among pregnant women; however, it is not known To improve service delivery, in 2014, the South Canterbury (DHB) introduced how many education sessions are required to maximize knowledge and self- specialist nurse OSA assessments under the supervision of our tertiary pro- management, and whether these improvements persist postpartum. vider, Christchurch Hospital. The aim of this project is to critically review the Methods: We conducted three prospective studies in pregnant women demographics and outcomes of the current OSA sleep pathway to benchmark with asthma recruited from the antenatal clinic: the ‘Phase II Asthma and Preg- efficiencies and help direct future service delivery. nancy Study [Phase II]’ from 2004 to 2006 (n =84), ‘Viral Exacerbations of Methods: Referral, demographic and outcome data for the calendar year Asthma during Pregnancy [VEAP]’ from 2007 to 2010 (n = 312), and the of 2014 were reviewed. ‘Breathing for Life Trial [BLT]’ which commenced in 2013 (n = 289). Baseline Results: Three hundred fourteen referrals were made to the South Canter- data from these studies were compared for medication use, ICS adherence, bury DHB OSA pathway form GPs, Physicians and ENT specialists. asthma control, device technique, medications knowledge and action plan Conclusions: Allowing the South Canterbury DHB patients with OSA bet- possession and use. Ninety-five women from VEAP underwent four assess- ter access to treatment for OSA has been a success for this service. The num- ments during pregnancy (monthly) and one assessment at 6 months postpar- ber of referrals for patients with no OSA and that some GPs do not refer tum. Changes in ICS use, adherence, device technique and medications challenges us to make contact with them and ensure equal access to the ser- knowledge were compared over time. vice for all patients with OSA within the South Canterbury DHB. Results: ICS use during pregnancy declined from 42% (95% CI Grant Support: Nil. 31.7–52.4%) among participants in Phase II, to 29.8% (25–35.1%) in VEAP and 18.3% (14.3–23.2%) in BLT (P < 0.0001). Possession of a written action plan declined from 20.2% in Phase II (95% CI 13% - 30%), and 23.9% in VEAP (19.5–29.0%) to 16.3% in BLT (95% CI 12.3–21.4%, P < 0.001). In the 95 participants with four pregnancy assessments and one postpartum assessment, maximum improvements were observed within two sessions for medications knowledge and device technique with skills maintained postpartum. However, ICS use and adherence were maximally improved after three sessions, but not maintained postpartum. Conclusions: Self-management skills of pregnant women with asthma did not improve between 2004 and 2015. Written action plans were possessed by <20% and ICS use remains low. More awareness of the importance of optimal asthma management during pregnancy is warranted. Grant Support: National Health and Medical Research Council. Declaration of interest: None to declare.

TO 008 Chronic Obstructive Pulmonary Disease 1 Oral Presentations HIGH-DOSE BETA2-AGONIST TREATMENT IS ASSOCIATED WITH CARDIAC DYSFUNCTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE

TO 007 SHAFUDDIN E1,2,COORAYM1, TUFFERY C1, HOPPING S1, SULLIVAN G1,JACOBSONG3, CHANG C1,HANCOXR1,2 1Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand, 2Department of Preventive and Social Medicine, Dunedin School OCCULT CARDIAC DISEASE CAN BE IDENTIFIED BY 3 of Medicine, University of Otago, Dunedin, New Zealand, School of Phar- DYNAMIC CT DURING COPD EXACERBATION macy, Faculty of Health, University of Tasmania, Hobart, Australia

MACDONALD M1,WONGA1,KINGP1,LOCKWOODS2, TROUPIS J3, 1 Introduction/Aim: Acute cardiac disease frequently occurs during COPD BARDIN P exacerbations. In our previous study, nebulised bronchodilator therapy inde- 1Monash Lung and Sleep, Monash Health, 2Monash Heart, Monash Health, 3 pendently predicted the increase in cardiac biomarkers during COPD exacer- Monash Imaging, Monash Health bations. In this study, we assessed the association between blood salbutamol levels and the rises in NT-proBNP and troponin T during COPD Introduction/Aim: Acute cardiac dysfunction during COPD exacerbations exacerbations. is associated with poor prognosis. It is common, yet consistently under-recog- Methods: One hundred seventeen admissions (94 patients) for COPD ex- nized in clinical practice. This partly reflects the specific limitations of echocar- acerbations from August 2012 to July 2013 had NT-proBNP and high-sensitiv- diography, chest X-ray (CXR) and ECG in an emphysematous population. We ity troponin T levels measured on admission and at 12 h. Blood salbutamol utilized a novel dynamic cardiopulmonary CT approach to explore cardiac levels at 12 h were determined using ultra-performance liquid chromato- dysfunction during COPD exacerbation. graph–mass spectrometry. We assessed whether blood salbutamol levels Methods: Forty-five patients with acute exacerbation of COPD underwent were correlated with the rises in NT-proBNP and troponin T levels after adjust- low radiation contrast enhanced 256-slice dynamic cardiac function CT. The ment for exacerbation severity—CURB-65 score and acidaemia (blood pH additional diagnostic yield of dynamic CT was compared to usual clinical less than 7.30). – care history/examination/ECG/CXR. Results: NT-proBNP significantly increased from a geometric mean of Results: Only 20% of the population had known IHD. CT identified signif- 43 pmol/L on admission to 51 pmol/L at 12 h (p = 0.0057). Ten patients icant coronary artery calcification in 53.3% (p = 0.001). Amongst those with (10%) had a clinically significant troponin T rise at 12 h. Blood salbutamol > extensive plaque (AU 400, n = 16) 50% were not taking antiplatelets or levels were positively correlated with NT-proBNP 12-h rise after adjustment statins, and only 6.3% were taking beta-blockers. Acute LV dysfunction for CURB-65 score and acidaemia (p < 0.05). Blood salbutamol levels were < (EF 55%) was identified in 15.6% by CT compared to 6.7% on clinical not significantly higher in patients with a troponin T rise than those without a < grounds (p = 0.19). CT identified RV dysfunction (EF 45%) in 27.9% v rise (geometric means total salbutamol 9.77 vs. 5.89 ng/mL, p = 0.0989). 15.6% on clinical grounds (p = 0.2). Pulmonary artery distensibility was signif- Conclusion: Blood salbutamol levels were positively correlated with an in- < icantly impaired (cross-sectional area change 15%) in 34.1% with only crease in NT-proBNP levels 12 h after admission for an exacerbation of 11.1% having clinically diagnosed pulmonary hypertension. The study popu- COPD independent of exacerbation severity. We suggest that excessive — lation had severe underlying emphysema mean emphysema index 15.5% salbutamol use may contribute to acute cardiac dysfunction in exacerbations ± 12.9(SD). Median radiation dose was low at 3.6 mSV. of COPD. ‘ ’ Conclusions: Dynamic CT frequently identifies clinically occult cardiac Grant Support: The study was financially supported by the Respiratory dysfunction in COPD exacerbation. This technique can perform simultaneous Research Unit, Department of Respiratory Medicine, Waikato Hospital. heart and lung evaluation at low radiation dose to optimize patient selection for Declaration of Interest Statement: We declare no conflicts of interest. therapeutic intervention.

TO 009 TO 010

QVA149 IS MORE EFFICACIOUS THAN TIOTROPIUM AND GLYCOPYRRONIUM SIGNIFICANTLY IMPROVES LUNG SALMETEROL/FLUTICASONE COMBINATION (SFC) IN FUNCTION, DYSPNEA AND HEALTH STATUS IN COPD IMPROVING PATIENT-REPORTED OUTCOMES AND LUNG PATIENTS IN ALL GOLD GROUPS FUNCTION IN COPD PATIENTS WITH MODERATE TO SEVERE BASELINE DYSPNOEA: THE IGNITE TRIALS FRITH P1,D’URZO A2,BADERG3, ALTMAN P4, GOYAL P3 1Respiratory Clinical Research Unit, Repatriation General Hospital, Southern WARK P1,MAHLERD2, KEININGER D3, FOGEL R4, MEZZI K3, BANERJI D4 Adelaide Local Health Network, Adelaide, Australia, 2University of Toronto, 1Centre for Asthma and Respiratory Disease, Hunter Medical Research Insti- Toronto, Canada, 3Novartis Pharma AG, Basel, Switzerland, 4Novartis tute, New Lambton, Australia, 2Geisel School of Medicine at Dartmouth, Pharmaceuticals Corporation, NJ, USA Hanover, NH, USA, 3Novartis Pharma AG, Basel, Switzerland, 4Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA Glycopyrronium (GLY) and tiotropium (TIO) are inhaled LAMAs recommended for COPD patients in all GOLD groups (A,B,C&D).1 GLY is effective Introduction: QVA149 is an approved once-daily dual bronchodilator for and well tolerated in moderate-to-severe COPD patients, similar to TIO, and maintenance treatment in patients with COPD. Here, we assessed the has faster onset and better bronchodilation in the first 4 h after first dose. efficacy of QVA149 in improving dyspnoea, health status and lung function GLY and TIO efficacy was analysed post hoc in patients by GOLD group (A,B, in COPD patients with moderate to severe baseline dyspnoea (GOLD C&D), with data from four randomized controlled clinical trials, pooled and Group-B) from SHINE and ILLUMINATE studies. adjusted by mix-model. Patient classification (A&C, fewer symptoms; B&D, Methods: Symptomatic patients from SHINE (N = 2144) and ILLUMINATE more symptoms) was based on baseline dyspnea index (BDI; ≥7/<7)2 and (N = 523) studies with baseline dyspnoea index (BDI) ≤7 (moderate to severe lung function (FEV1; 50% predicted normal) not considering baseline dyspnoea equivalent to GOLD Group B) were included in this subgroup exacerbation risk. Efficacy of GLY and TIO was measured by mean change analysis. from baseline at 12 weeks for trough FEV1 (tFEV1), health status (SGRQ QVA149 was compared to placebo (PBO), open label tiotropium (TIO) and score) and dyspnea (TDI score). SFC; TDI, SGRQ and lung function (trough and pre-dose FEV1) were Out of 2599 patients (GLY = 1628; TIO = 971), 30.6% and 26.7% were in the assessed at week 26. low-symptom groups A&C, with baseline mean (SD) BDI scores of 5.11 (1.31) Results: Mean BDI was comparable in both SHINE [QVA149 (n = 305): and 4.72 (1.47), respectively, and baseline FEV1 % predicted normal mean 5.44, TIO (n = 313): 5.57, PBO (n = 131): 5.47] and ILLUMINATE [QVA149 (SD) 62.54 (7.94) and 40.50 (6.07); 29.7% and 13.1% patients were in the (n = 166): 5.78, SFC (n = 179): 5.85] studies. QVA149 provided significant high-symptom groups B&D, respectively, with BDI = 8.18(1.29) and 7.95 improvement in dyspnoea and lung function, compared with PBO, TIO and (1.23) and baseline FEV1% predicted normal = 64.66(8.58) and 41.85(5.68), SFC (Table). QVA149 also improved (not significant) SGRQ total score respectively. Based on the least square means change from baseline at versus SFC. 12 weeks, GLY led to statistically significant and clinically relevant improve- Table: Treatment differences at week 26 ments in tFEV1, dyspnea and health status in all GOLD groups; there was no significant difference between GLY and TIO. SHINE ILLUMINATE In conclusion, GLY improved lung function, dyspnea and health status in COPD patients in all GOLD groups, similar to TIO. – Parameter QVA149—PBO QVA149—TIO QVA149—SFC GOLD 2015Ozalevli et al. 2006 J Eval Clin Pract 12;532 538 Grant Support: These studies were sponsored by Novartis Pharma AG, Basel, Switzerland. TDI score 1.0 (0.3) 0.6 (0.2) 1.0 (0.3) SGRQ score À2.9 (1.3) À2.0 (1.0) -1.4 (1.3) FEV1, ml 200 (20) 70 (16) 100 (24)

Data are least squares mean (standard error); ‡trough; †pre-dose FEV1; ¤clinically meaningful; *p < 0.05. Conclusion: In patients with moderate to severe baseline dyspnoea (comparable with GOLD Group-B), QVA149 was more efficacious than TIO and SFC in improving patient reported outcomes and lung functions. Grant Support: These studies were sponsored by Novartis Pharma AG, Basel, Switzerland.

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PERIPHERAL BLOOD EOSINOPHILIA, STEROID USE AND BLOOD EOSINOPHILS AS A SURROGATE MARKER FOR RECURRENT PRESENTATIONS IN HOSPITALISED PATIENTS SPUTUM EOSINOPHILIA IN STABLE COPD WITH COPD NEGEWO N1,MCDONALDV1,2,3,BAINESK1,WARKP1,2, SIMPSON J1, BELOUSOVA N, BROCKBANK S, KIM N, CHUNG S, HOUGHTON B JONES P4,GIBSONP1,2 Port Macquarie Base Hospital 1Priority Research Centre for Asthma and Respiratory Diseases and Hunter Medical Research Institute, The University of Newcastle, New South Wales, 2 Introduction: Peripheral blood eosinophilia is a potential biomarker for ste- Australia, Department of Respiratory and Sleep Medicine, John Hunter Hos- 3 roid response in COPD. Pre-admission use of oral steroids may impact on the pital, New South Wales, Australia, School of Nursing and Midwifery, The Uni- 4 clinical usefulness of this biomarker in the hospital setting. versity of Newcastle, New South Wales, Australia., Institute for Infection and Aims: Immunity, St George’s University of London Cranmer Terrace, London, UK 1 To determine the frequency of peripheral blood eosinophilia in patients admitted to hospital with exacerbations of COPD. Introduction: Sputum eosinophilia occurs in about 30% of stable COPD 2 To explore the association between oral steroid use, eosinophilia and ex- patients and can predict exacerbation risk and response to corticosteroids. acerbation rate. Reliable and easily accessible biomarkers that can identify sputum eosino- Methods: We reviewed the electronic records of all patients admitted to philia are needed. Port Macquarie Base Hospital with an exacerbation of COPD in 2014. Inhaled Aims: Our aims are to investigate the correlation and predictive relation- and oral steroid use and the initial full blood count at the time of presentation ships between peripheral blood eosinophils (PBE) and sputum eosinophilia were recorded. Percentage peripheral blood eosinophil count was calculated in stable COPD and to evaluate the repeatability of PBE counts. from the absolute white cell count and eosinophil count. An eosinophil count Methods: Stable COPD patients (n = 141) (GOLD grades I–IV) were >2% was considered elevated. assessed for lung function and airway and peripheral blood inflammatory cell Results: There were 333 admissions for COPD. Two hundred fifteen out of counts. Receiver operating characteristic (ROC) curve analysis was used to 333 (65%) were receiving inhaled steroid and 96/333 (29%) had commenced assess the predictive relationship between PBE and sputum eosinophilia oral steroid therapy prior to admission. There were 54/333 (16%) admissions (≥3% sputum eosinophils). The repeatability of PBE counts between two mea- with a raised eosinophil count. Of these, 14/54 (26%) were on oral steroid and surements (approximately 28 days apart) was determined using intra-class 36/54 (67%) were on inhaled steroid. Eosinophilia was found in 14/96 (16%) of correlation coefficient (ICC) (n = 46). patients on oral steroids. Fifty-seven patients included in the study had more Results: The mean age was 69.8 ± 7.7 (SD) years, 89 (63.1%) were male than one presentation in the 12-month period. Sixteen out of 57 (28%) of these and mean post-bronchodilator predicted FEV1 was 57.5 ± 17.9% (SD). Within patients had eosinophilia. the group 74 (52.5%) were frequent exacerbators (≥2 exacerbations). Sputum Conclusions: Despite frequent use of oral steroids prior to admission, a eosinophilia was present in 45 (31.9%) patients. PBE counts were significantly modest proportion of patients have peripheral blood eosinophilia. There is a higher in those with sputum eosinophilia compared to those without (0.30 ver- trend towards higher rates of eosinophilia among patients with recurrent ad- sus 0.15(×109/L); p < 0.0001). PBE correlated with both the proportion and missions. Peripheral blood eosinophilia may have clinical utility in the acute number of sputum eosinophils (correlation coefficients of 0.535; p < 0.0001 hospital setting. and 0.473; p < 0.0001, respectively). Absolute PBE count was predictive of Grant Support: Nil. sputum eosinophilia with area under the curve of 0.76 (95%CI: 0.67–0.84; p < 0.0001). At the optimal threshold of ≥0.3 × 109/L, PBE identified the presence or absence of sputum eosinophilia in 71% of the cases (specificity = 76%, sensitivity = 60%, positive likelihood ratio (+LR) = 2.5). A threshold of ≥0.4 × 109/L had similar classifying ability but better specificity (91.7%) and higher + LR (3.7). In contrast, ≥0.2 × 109/L offered a better sensitivity (91.1%) for ruling-out sputum eosinophilia. The repeatability of PBE counts was good (ICC = 0.8; 95%CI: 0.66–0.88; p < 0.0001). Conclusion: PBE can identify the presence or absence of sputum eosinophilia in stable COPD with a moderate degree of accuracy. Grant Support: NHMRC (grant ID: 1045230; PG, VM, JS, PA.B.W), NHMRC (grant ID: 455508, 2007–2010), Ramaciotti Foundation (VMcD), Lung Foundation of Australia (VMcD), PRC for Asthma and Respiratory Dis- eases PhD Scholarship and Emlyn and Jennie Thomas Postgraduate Medi- cal Research Scholarship through HMRI (NAN).

TO 014 Primary Care 1 Oral Presentations

HOW DOES THE PATIENT FEEL ABOUT THEIR ALLERGIC RHINITIS? TO 013 CVETKOVSKI B1,YANK2,KRITIKOSV1, BOSNIC-ANTICEVICH S1,3 1Woolcock Institute of Medical Research, 2Royal Prince Alfred Hospital, 3Sydney Local Health District PHARMACY STUDENTS AND PAEDIATRIC ASTHMA COMMUNICATION: IMPACT OF AN EVIDENCE-BASED Introduction: Preliminary research with people with asthma showed that PROGRAM 90% of study population suffered from nasal symptoms with only 26% using intranasal corticosteroid treatment. As poor asthma control and poorly man- ELARO A1,SHAHS2, SAINI B3,ARMOURC1, BOSNIC-ANTICEVICH S1 aged allergic rhinitis (AR) are linked, this statistic warranted further investiga- 1The Woolcock Institute of Medical Research, University of Sydney, Australia, tion into the management of AR. 2Primary Health Care Education and Research Unit, Western Sydney Local Aim: The study aims to investigate the management of AR from the perspec- Health District, Sydney, Australia, 3Faculty of Pharmacy, University of tive of the patient and to describe their health network using social network theory. Sydney, Australia Methods: People suffering from AR were invited to participate in a qualitative semi-structured interview incorporating social network theory on their AR Introduction: Patient-centred pharmaceutical care is being encouraged on with opportunity to discuss asthma if co-existing. Interviews were transcribed an international scale. Pharmacy graduates must be able to communicate verbatim and qualitatively analysed for emerging themes. with paediatric patients, caregivers and other involved healthcare providers Results: Forty-three participants (31 female) were interviewed about their to improve clinical and economic outcomes and to ensure effective delivery allergic rhinitis and asthma if co-existing (18 participants). A majority of partic- of patient-centred care. The Practitioner Asthma Communication and Educa- ipants had experienced predominantly nasal and ocular symptoms since tion (PACE) programme contains an evidence-based communication frame- childhood with many having received allergy testing and able to identify partic- work that has allowed pharmacists and physicians to gain an increased ular triggers. The majority of medical attention received appeared to be con- sense of self-confidence, greater intrinsic motivation and higher achievement. centrated during these early years and managed by the parents. This study assessed the impact of the PACE programme on pharmacy In adulthood, participants predominantly self-managed their symptoms with a students behaviours and self-perceived ability to communicate with/educate strong preference not to medicate unless the symptoms were severe or paediatric asthma patients and their caregivers. impacting on their lifestyle or workplace. While some participants with severe Methods: This study took the form of a pre–post study design. Pharmacy symptoms and co-existing asthma sought the advice of their medical practi- students were trained in the PACE programme. Students were asked to reflect tioner, many participants relied on their own experimentation, recommenda- on their encounters with paediatric asthma patients/caregivers during their tions from fellow allergy sufferers particularly close family and friends and clinical placements and to report on four domains pre and 1 month post-PACE occasionally a pharmacist. programme completion. The first three domains related to their confidence, Conclusions: People that suffer from AR consider the symptoms a nui- beliefs of the helpfulness and frequency of use of evidence-based communi- sance but are reluctant to medically manage them. While they recognize that cation strategies. The final domain related to pharmacy students’ ability to healthcare professionals can be of assistance, they feel that they adequately self-reflect on the use/effectiveness of their communication practices. The self-manage their symptoms and that further medical attention is not warranted. mean pharmacy student self-reported scores for each item in Domains 1–4 were calculated and compared using a paired samples Student’s T-test (significance 0.05, power 0.8). Results: Pharmacy students (n = 209) provided data pre and 1-month post participation in the PACE programme. Pharmacy student self-reported data showed a statistically significant increase in confidence and frequency of use of evidence-based communication strategies, beliefs in the helpfulness of communication strategies and in their ability to self-reflect on the use/effectiveness of strategies (see table).

Pre- Post- program program P- Domains: (n =209) (n = 209) Change value

1. Confidence in using 3.5 3.9 0.4 0.000 communication strategies (1 = not at all confident, 5 = very confident) 2. Beliefs in the helpfulness 4.3 4.4 0.1 0.020 of communication strategies (1 = not helpful 5 = very helpful) 3. Frequency of use of 3.4 3.8 0.4 0.001 communication strategies (1 = never to 5 = very often) 4. Ability to self-reflect on the 3.7 4.3 0.6 0.000 use/effectiveness of their communication practices (1 = never to 6 = always)

Conclusions: This study supports the value of integrating the evidence- based PACE programme into the pharmacy coursework as it improves student behaviours in the clinical environment. This may lead to an improvement in pharmacists’ communication confidence and practices around paediatric asthma when they enter the workforce. Grant Support Australian Postgraduate Award.

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QUALITY USE OF RESPIRATORY MEDICATIONS IN PEOPLE WITH COGNITIVE IMPAIRMENT DEVELOPMENT OF A TAILORED GOAL-SETTING SELF- 1 2 3 1 1 MANAGEMENT APP FOR YOUNG PEOPLE WITH ASTHMA DAVIS S , DURVASULA S ,MERHID, YOUNG P ,TRAINID, BOSNIC- ANTICEVICH S1 1 2 SMITH L1, PETERS D2,DAVISS3,CALVOR2,SAWYERS4,FOSTERJ3 Woolcock Institute of Medical Research,University of Sydney, Centre for 1 2 Disability Studies, University of Sydney, 3Synergy Medical Practice Faculty of Pharmacy, University of Sydney, School of Electrical and Informa- tion Engineering, University of Sydney, 3Clinical Management Group, 4 Introduction: Up to 90% of inhaler users do not use them well enough to Woolcock Institute of Medical Research, University of Sydney, RCH Centre for Adolescent Health; Department of Paediatrics, The University of benefit from the prescribed therapy, as they are complex, non-intuitive de- 5 vices, requiring physical and cognitive ability. Melbourne, Clinical Management Group, Woolcock Institute of Medical People with intellectual disability (ID) have a high burden of respiratory dis- Research, University of Sydney ease. Based on their cognitive, and sometimes physical and sensory impairments, people with ID potentially are at increased risk of inhaler misuse. Introduction: The growing interest in new media, including apps, for They may self-manage their asthma medications or rely on caregivers for supporting self-management in chronic health conditions is particularly rele- asthma medication support. The aim of this research was to explore issues vant to young people with asthma, given the prevalence of asthma and uptake around inhaler use in people with ID. of new technologies by youth. The majority of existing asthma apps available Methods: Mixed methods incorporating quantitative and qualitative tech- lack an evidence base, and have failed to involve end users in their develop- niques were used to characterize respiratory medication management in peo- ment. This pilot study aimed to engage young people with asthma in the de- ple with ID, understand their knowledge of asthma medication use, examine sign of an evidence-based app to support them in asthma self-management. – how people with mild ID actually use their inhalers and explore the role of care- Methods: Young people aged 15 25 years participated in a workshop and/ givers in asthma medication management. or completed a workbook or questionnaire on their thoughts and ideas about Results: This research showed that people with ID were prescribed in- living with asthma, technology use and design ideas for an asthma goal-set- halers—often more than one device type. Comorbid conditions and high ting app. Mock smartphone screens, collages and concept maps were cre- levels of medication use were noted, which may affect healthcare professional ated by participants to record their preferences. Demographic characteristics management of asthma for these patients. Identified barriers to asthma med- including medication use and the asthma control test (ACT) were collected. ication self-management included poor knowledge of medication side effects Workshop sessions and workbook content were transcribed and analysed and dosage, low uptake of spacers and the stigma of using inhalers in public. thematically to extract design and content features for the app. Caregivers perceived that they themselves need more suitable decision-sup- Results: Six participants attended a workshop and 12 completed a work- port tools to assist their clients with deteriorating respiratory function. book. Participants (mean age 18.2 years; 58% female; 83% prescribed ICS) – Conclusions: Potential areas for improvement include prescribing of the had disparate asthma control (mean ACT: 19, range 15 23). Design features fewest number of device types, individualized tailored education and support considered important were a simple and professional user interface, for caregivers by means of training in inhaler use and asthma attack decision customisable notifications, ability to connect to others with asthma, easy support. To enable quality use of respiratory medications in people with ID, access to emergency information and access to asthma-related information. health professionals need to be proficient in communicating with people with Desired goal-setting features included increasing health/life control (auton- ID. Development of respiratory care recommendations for this vulnerable omy), participating in peer activities (competence) and connecting with peers group is a priority. (relatedness). These features are consistent with goal-setting and self-deter- Grant Support: No funding was received for this research. mination theory. Declaration of Interest Statement: The authors declare that there are no Conclusions: Key identified design and content features will be utilized in conflicts of interest. the next stage of app development. Results will be integrated into the design of an asthma-support app that is user-centric, age-appropriate and has optimal effectiveness for improving self-management in young people. Grant Support—Funding for this study was received from Asthma Australia.

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MANAGEMENT OF PULMONARY EMBOLISM IN OUTPATIENT PROVISION OF ONE-ON-ONE PATIENT EDUCATION AND SETTING: RETROSPECTIVE CASE SERIES COACHING OVER THE PHONE CAN IMPROVE ASTHMA CONTROL IN PEOPLE WITH ASTHMA CHANG V, BASKARAN R, YEONG C, HSU K, FRANKEL A Bankstown Hospital MURRAY P1,CORCORANK2, HARRIS-ROXAS B3, JENKINS C2 1Asthma Australia, 2George Institute for Global Health, 3ZEST Health Introduction/Aim: There is growing evidence that sub-massive acute pul- Strategies monary embolism (PE) can be managed in the outpatient setting. Currently, there is limited literature or well-defined clinical pathway in selection of patients Introduction/Aim: The Asthma Australia Community Support Program for early discharge and outpatient management. Our study incorporates Pul- (CSP) through its project Follow Up, provides one-on-one patient education monary Embolism Severity Index (PESI) for selection of low risk patients for and coaching to people with poorly controlled asthma over the phone. Follow treatment as outpatients in the ambulatory care programme and describes Up is designed to improve participants’ asthma control in conjunction with their the adverse clinical outcomes and treatment complications. general practitioner (GP). We report the effectiveness of Follow Up in improv- Methods: Ninety-six patients were treated for PE in ambulatory care over a ing asthma control in a real world community setting. 6-month period in 2014. Twenty patients were treated with rivaroxaban; three Methods: All participants referred into Follow Up and consenting to partic- were treated with Enoxaparin only and the rest were treated with enoxaparin ipate from 1 July 2014 to 30 September 2015 were included. Participants were followed by warfarin. We reviewed the demographic and clinical data and referred from a several sources across the country including general practice, PESI of the patients and reported on the incidence of complications, including pharmacy and hospitals. major bleeding, recurrent PE and mortality. Participants receive an initial education session undertaken by a qualified Results: Mean age for the study population was 70 years. Seventy-four asthma educator or practitioner, including goal setting on asthma self-man- percent of patients were female. The programme was successfully completed agement education and the Asthma Control Test (ACT). Encouraging partici- by 94% of patients. There were four episodes of major bleeding (4%) and two pants to obtain a Written Asthma Action Plan and seeing their GP for an episodes of interval PE (2%). One died within 1 month of admission to the pro- asthma review is a vital consideration in the goal setting process. Six weeks gramme, but this was not attributable to PE or complication of treatment. later, people receive a follow-up phone call to assess action taken on specified Three out of six patients with complications had low risk PESI scores, whilst goals, provide education as required and re-administer the ACT. Demo- the other three were intermediate/high risk. The complication rates for warfarin graphic data items are also collected. and rivaroxaban treatment groups were 4% and 5%, respectively. Results: Of 1078 participants who consented to Follow Up at the time of re- Conclusions: In our experience, most patients with sub-massive PE were ferral, 535 completed at least one coaching session. At the 6 week follow-up, successfully managed in outpatient setting. PESI score alone was not predic- 153 of 231 participants had an improvement in asthma control with an average tive of complications in outpatient management of patients with sub-massive improvement of 5.3 in their ACT score, from mean 15.1 (±5.4 SD) to 19.4 (±4.9 PE. A larger study for patient selection is required to refine the pathway for out- SD). Patients determine self-management goals: for those indicating seeing patient treatment of PE. GP for a review 36.2% did so, and 30.8% of patients obtained a WAAP. Grant Support: Nil. Conclusion: Clinically significant improvements in asthma control can be Declaration of interest:Nil. achieved in patients with poorly controlled asthma who receive one-on-one phone coaching through the CSP. A prospective longer-term study is needed to confirm these findings. Grant Support: This study was supported by the Department of Health, Community Support Program for asthma management.

TO 020 Cell Biology/Immunology 1 Oral Presentations

DIFFERENTIAL SUBCELLULAR LOCALIZATION AND EXPRESSION OF SPINSTER HOMOLOG 2 (DROSOPHILA) IN AIRWAY EPITHELIAL CELLS AND MACROPHAGES IN TO 019 RESPONSE TO CIGARETTE SMOKE AND IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE MAY CONTRIBUTE TO MACROPHAGE PHAGOCYTIC DYSFUNCTION LINEAGE AND PHENOTYPICAL CHARACTERISTICS OF CONDITIONALLY REPROGRAMMED PRIMARY AIRWAY AND TRAN H1,HAMONR1,WEENM1, HODGE G1,2, ROSCIOLI E1, BARNAWI NASAL EPITHELIAL CELLS: A PILOT COMPARISON STUDY J1,2,3, REYNOLDS P1,2,PITSONS2,4, HABERBERGER R5, HODGE S1,2 1Royal Adelaide Hospital, 2University of Adelaide Department of Medicine, 1 2,3 1 1,4 3University of Tabuk Department of Medical Laboratory Technology, 4SA Pa- MARTINOVICH K , IOSIFIDIS T ,LINGK,SUTANTOE ,KICIC- 5 STARCEVICH E1,4, GARRATT L1,SHAWN1, BUCKLEY A5,MONTGOM- thology Centre for Cancer Biology, Flinders University Centre for Neurosci- ERY S3, LOO K1, LANNIGAN F6,KNIGHTD7,8,9,KICICA1,2,3,4,STICKS1,2,3,4 ence, Anatomy & Histology 1Telethon Kids Institute, Subiaco, WA, 2School of Paediatrics and Child Health, The University of Western Australia, Nedlands, WA, 3Centre for Cell Introduction: We previously showed a decreased lung protein expression Therapy and Regenerative Medicine, School of Medicine and Pharmacology, of the sphingosine 1 phosphate (S1P) transporter, spinster homolog 2 (dro- The University of Western Australia, Nedlands, WA, 4Department of Respira- sophila) (SPNS2), in cigarette smoke-exposed mice, and that exogenous tory Medicine, Princess Margaret Hospital for Children, Perth, WA, 5Centre for S1P rescued macrophages from suppressive effects of cigarette smoke on Microscopy, Characterisation and Analysis, The University of Western phagocytosis. In this study, we further investigated SPNS2 subcellular locali- Australia, Nedlands, WA, 6School of Medicine, Notre Dame University, zation, expression and response to cigarette smoke exposure in both macro- Fremantle, WA, 7School of Biomedical Sciences and Pharmacy, University phage and epithelial cell types. of Newcastle, Callaghan, NSW, 8Priority Research Centre for Asthma and Methods: We investigated lung tissue sections from COPD patients/ Respiratory Disease, Hunter Medical Research Institute, Newcastle, NSW, smokers and cigarette smoke-exposed mice, BAL-derived alveolar macro- 9Department of Anaesthesiology, Pharmacology and Therapeutics, University phages from COPD patients/smokers and controls, and 16HBE epithelial of British Columbia, Vancouver, Canada, and THP-1 macrophage cell lines exposed to cigarette smoke extract, or vehicle control. Gene expression was analysed by RT-PCR, protein subcellular lo- Introduction: The airway epithelium is involved in pathogenesis of child- calization by confocal microscopy, flow-cytometry and cell fractionation hood respiratory diseases including asthma and cystic fibrosis. Research pro- followed by Western blots. gression in these areas is reliant on accurate and reflective modelling, and Results: In epithelial cells, SPNS2 was associated with plasma mem- primary airway epithelial cultures remain the gold standard. However, ad- brane, cytoplasm and nucleus. Epithelial cells exhibited a marked SPNS2 vancements are restricted by limited access to the lower airway, number of down-regulation, in both cigarette smoke-exposed mice (protein ~ -60%, < cells obtained and ability to expand primary cell cultures. Given this, nasal ep- p 0.001) and cigarette smoke extract-treated cell cultures (protein ~ -70%, < ithelial cells may be a surrogate, since they are easier to obtain and require a p 0.001). In contrast, in macrophages SPNS2 was mostly localized to the less invasive sampling method. This pilot study compared the culture expan- nucleus. By bioinformatics analysis, a bipartile nuclear localization signal sion potential of both cell populations via conditional reprogramming. was predicted at the position aa282 of the human SPNS2 sequence. In line < Methods: Primary airway (3 M:1 F; 5.9 ± 3.1 years) and nasal (3 M:1 F; 6.0 with a statistically significant (p 0.05) increase of SPNS2 mRNA in alveolar ± 3.8 years) epithelial cells from healthy children were obtained, processed macrophages of COPD, patients/smokers compared to nonsmoker controls, and conditionally reprogrammed by co-culturing with irradiated fibroblast cigarette smoke extract-treated THP-1 macrophages showed SPNS2 expres- < feeder cells in medium containing ROCK inhibitor. Population doublings, cell sion upregulated at both mRNA and protein levels (p 0.05). Alveolar macro- yield and epithelial phenotype was compared and confirmed via cell counts, phages from smoke-exposed mice showed only a non-significant trend for qPCR, western blot and immunocytochemistry using cytokeratin (CK)-19, increased SPNS2 immunoreactivity. CK-5/14 and vimentin expression. Finally, cultures were compared in their Conclusion: Differential contribution of airway epithelial cells and macro- ‘ ’ ability to terminally differentiation at air–liquid interface. phages to defective S1P signalling via SPNS2 may reflect a cross-cell type Results: Airway (A) and Nasal (N) epithelial cells were successfully interaction and provide a mechanism for macrophage dysfunction in COPD. established, expanded and maintained over at least seven passages. How- Grant support:NHMRC ever, a subset of cultures was easily maintained beyond this. Conventional Declaration of interest statement: The authors declare no conflict of cobblestone morphology was seen and maintained in both airway and nasal interest. samples. Doubling times were slightly faster in airway samples (n =4, Slope-A = 0.527 ± 0.013; N = 0.397 ± 0.009; p = 0.001), and cell yields were comparable (n = 18, A = 102.3 ± 25.99; N = 84.75 ± 26.55). Epithelial phenotype was maintained throughout culture, although nasal cultures had higher CK5/14 protein expression (n =4,p = 0.0037). Airway and nasal cells could both terminally differentiate, forming multiple cell layers, produce mucus and cilia. Conclusion: Large scale expansion of both airway and nasal samples with similar epithelial phenotypes is possible utilizing this new methodology. Given the similarities, nasal cells could be a surrogate for selected epithelial studies.

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MODELLING EPITHELIAL-MESENCHYMAL TRANSITION IN COCONUT OIL SUBSTITUTION IN DIESEL FUEL ALTERS CHRONIC OBSTRUCTIVE PULMONARY DISEASE USING HUMAN BRONCHIAL EPITHELIAL CELL RESPONSES TO PRIMARY HUMAN BRONCHIAL EPITHELIAL CELLS DIESEL EMISSION EXPOSURE AT THE AIR–LIQUID INTERFACE IN VITRO SPAFFORD P, COURTNEY J, WALTERS E BreatheWell NHMRC CRE, University of Tasmania VAUGHAN A1,STEVANOVICS2,ZAREA2,RAHMANM2, MILJEVIC B2, RISTOVSKI Z2,BOWMANR1,FONGK1,YANGI1 Introduction/Aim: Epithelial-mesenchymal transition (EMT) has been im- 1UQ Thoracic Research Centre, The Prince Charles Hospital, QLD, Australia, plicated in the development of chronic obstructive pulmonary disease (COPD) 2International Laboratory for Air Quality and Health, QUT, QLD, Australia and may potentially provide an explanation for the high incidence of lung cancer in COPD. It may be a crucial early stage process in COPD, as it occurs Introduction/Aim: Diesel and biodiesel emission toxicity studies will im- somewhat even in the airways of smokers without COPD. In vitro modelling prove the current understanding of how air pollution exposure may lead to ad- of EMT could provide insight into mechanisms of COPD airway pathology verse health effects. The aim of this study was to investigate the cellular and may suggest new potential avenues of treatment. responses of human bronchial epithelial cells to diesel and biodiesel emis- A model of disease processes should recapitulate, as accurately as possible, sions (percentage fuel substitution with coconut oil) at an air–liquid interface in vivo disease processes. This work aimed to develop a better model and (ALI). deeper understanding of EMT in COPD using primary bronchial epithelial cells Methods: Human bronchial epithelial cells, 16HBE, were cultured at an ALI (pHBECs) taken from non-smokers and people with COPD. and exposed to diesel and biodiesel emissions (percentage substitution with Methods: pHBECs were assessed for expression of EMT markers using coconut oil—10%, 15% and 20%) for 30 min. Human bronchial epithelial cell qRT-PCR and Western blots. PHBECs from non-smokers were also induced responses were measured as cell viability and cytokine secretion (IL-8 and to undergo EMT using TGF-β and compared to COPD pHBECs. IL-6). Results: COPD pHBECs had increased levels of the mesenchymal pro- Results: Diesel and biodiesel emission exposure resulted in a significant teins N-cadherin, vimentin and S100A4 compared to non-smokers, indicating reduction in cell viability when compared to the filtered air control. This was that EMT is potentially occurring. TGF-β, which is known to induce EMT in significantly attenuated by a 20% substitution with coconut oil, when com- bronchial epithelial cells, caused normal pHBECs to undergo EMT, with N- pared to diesel emission exposure. Diesel and biodiesel (coconut oil substitu- cadherin RNA levels increasing eight-fold, vimentin increasing two-fold but tion) emission exposure resulted in a significant increase in IL-8 and IL-6 S100A4 decreasing by half. This is a potentially useful model of EMT, and secretion. Results are summarized in the table below. n = 2 (with triplicate could be used to study EMT in COPD. Paradoxically, at the RNA level COPD samples) ± SEM, * indicates a significant difference (P < 0.05) when com- pHBECs expressed five-fold less N-cadherin, three-fold less vimentin and pared to the filtered air control. seven-fold less S100A4. This suggests post-transcriptional regulation of EMT protein expression in COPD and indicates TGF-β stimulation may not Biodiesel—Percentage (%) be ideal for producing a model of EMT in COPD. coconut oil substitution Conclusion: In conclusion, this work has added to the evidence for EMT in COPD and has provided some insight into possible mechanisms of regulation. Cell response Filtered Diesel 10% 15% 20% Further work is needed to clarify the mechanisms which underpin EMT activity in COPD. air Grant Support: NHMRC and The Australian Lung Foundation. We ac- Cell viability 100±0 33.5* 33.1*± 33.9*± 68.1*± knowledge the help of all Royal Hobart Hospital respiratory clinicians in the (%) ±3.2 4.2 6.7 6.9 collection of samples for this project. IL-8 secretion 1139± 2339*± 4904*± 4331*± 2291± (pg/mL) 82.6 429.8 589.7 360.2 322.3 IL-6 secretion 1249± 9310*± 5373± 5841*± 6238*± (pg/mL) 64.9 1966 695.3 841.4 751.5

Conclusion: Biodiesel emissions may be less harmful to human bronchial epithelial cells than diesel emissions. Coconut oil substitution in diesel fuel may be a potential intervention to reduce the adverse health effects associated with air pollution. Grant Support: The Prince Charles Hospital Foundation (AV), ARC Discovery Grant, NHMRC Career Development Fellowship (IY) and NHMRC Practitioner Fellowship (KF).

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NOVEL SETD7 SPLICE VARIANT INDUCES EPIGENETIC MAPPING AND IDENTIFYING MIGRATION PATTERN CHANGES AFFECTING THE FUNCTION OF ASTHMATIC DIFFERENCES IN RESPONSE TO WOUNDING IN ASTHMATIC CELLS AND NON-ASTHMATIC AIRWAY EPITHELIAL CELLS

BALTIC S, BARRETT L, KIDD C, THOMPSON P IOSIFIDIS T1, BUCKLEY A3,4,SUTANTOE3,5,LINGK3,LOOIK1,3, Institute for Respiratory Health, University of Western Australia, WA, Australia GARRATT L1,3, KICIC-STARCEVICH E3,5, MARTINOVICH K3,SHAWN3, MONTGOMERY S1, VIJAYASEKARAN S1,LANNIGANF1,6,RIGBYP4, 7,8,9 1,2,3,5 1,2,3,5 Introduction/Aim: Alternative splicing, affecting more than 95% of all hu- KNIGHT D ,STICKS ,KICICA 1 2 man genes, increases the diversity of the transcriptome and proteome. An im- The University of Western Australia, Centre for Cell Therapy & Regenerative 3 balance in expressed splice-variants can lead to disease development or Medicine, Western Australia, Australia, Telethon Kids Institute, Western 4 impact on disease severity. We have identified the novel splice variant in his- Australia, Australia, Centre for Microscopy, Characterisation and Analysis, 5 tone-modifying gene lysine methyltransferase 7 (SETD7), and we aimed to in- Western Australia, Australia, Department of Respiratory Medicine, Princess 6 vestigate the effects of alternative splicing on the function of SETD7 and the Margaret Hospital for Children, Western Australia, Australia, School of Med- 7 potential impacts for asthmatics. icine, Notre Dame University, Western Australia, Australia, School of Methods: Wild type (wt) and splice variants for SETD7 were isolated, Biomedical Sciences & Pharmacy, University of Newcastle, New South 8 cloned into expression vector and stably transfected into 16HBE airway epi- Wales, Australia, Priority Research Centre for Asthma & Respiratory thelial cell line. We assessed levels of histone modifications, cell proliferation, Disease, Hunter Medical Research Institute, New South Wales, Australia, 9 wound healing, and cytokine and chemokine expression of cells overexpress- Department of Anesthesiology, Pharmacology & Therapeutics, University ing these variants. of British Columbia, British Columbia, Canada Results: SETD7 wt-expressing cells were found to have a heightened proliferation rate compared to untransfected 16HBE, but SETD7sv-transfected Introduction/Aim: Cell migration represents a significant component of the cells show significantly reduced proliferation rate in comparison. Assessment airway epithelial wound repair process. However, the pattern of migration and of wound healing found that the SETD7sv expressing cell lines have impaired cell directionality has not been investigated in these cells before. Since defec- ability to migrate compared to their WT expressing counterparts. tive cell migration is thought to contribute to the dysregulated wound repair of We have also assessed the impact of the alternative splicing in SETD7 on the asthmatic epithelium, the aim of this study was to analyse cell migration pat- histone 3 modification patterns. SETD7 splice variants seems to be non-func- terns and trajectories in asthmatic and non-asthmatic airway epithelial cells tional decreasing methylation of repressive marks H3K9me2 and H3K27me2, (pAECs) post-injury. but also plays a role in methylation of activation marks, such as H3K4me2, Methods: pAECs were obtained from (n = 4, 3 males, 3.1–12.7 years) H3K36me1 and H3K9me1. The expression of genes including central im- asthmatic and non-asthmatic (n = 7, 4 males, 2.1–7.1 years) children under- mune genes associated with asthma is affected by these. going elective surgery for non-respiratory conditions. Cells were initially cul- Conclusion: We have shown that overexpression of SETD7sv causes epi- tured and subsequently seeded into 96-well ImageLock plates. Once genetics changes hindering epithelial cell viability and wound closure abilities confluent, monolayers were mechanically wounded and repair tracked using and production of inflammatory mediators which may have functional signifi- brightfield images of the wound taken every 30 min (Incucyte; Essen Biosci- cance in asthmatic airways. ence). Migration patterns and trajectories of leading-edge cells were deter- Grant Support: Asthma Foundation WA. mined using ImageJ2 and the Chemotaxis and Migration Tool (Ibidi) plugin. Results: Leading-edge pAECs from non-asthmatic children were found to have a mean migration distance of 188 ± 79 μm and velocity of 0.37 ± 0.17 μm/ min. Primary leading-edge cells were found to have an angular distribution of 98° with a directionality value of 0.91 ± 0.10 during wound repair. Interestingly, leading-edge pAECs from asthmatic children were found to have similar mean migration distance and velocity to their non-asthmatic counterparts (181 ± 127 μm and 0.41 ± 0.28 μm/min, respectively). Primary leading-edge cells of asthmatic pAECs were found to have greater angular distribution of 267° and lower directionality value of 0.53 ± 0.19 during wound repair. Further analysis revealed that asthmatic pAECs could be further subclassed as ‘responders’ and ‘non-responders’ according to their migration trajectories post-wounding. Conclusion: Significant differences in cell directionality were observed between asthmatic and non-asthmatic pAECs. This is the first study to map and establish migration patterns of asthmatic pAECs post-wounding and correlates poor migrational response to dysregulated wound repair. Grant Support: NHMRC(#1048910), APA(UWA), Centre for Cell Therapy & Regenerative Medicine PhD Top-Up Scholarship.

TO 026 Asthma and Allergy 1 Oral Presentations

MATERNAL HYPOXIA-INDUCED INTRAUTERINE GROWTH RESTRICTION PREDISPOSED OFFSPRING TO AIRWAY HYPERRESPONSIVENESS IN ADULTHOOD TO 025

WANG K1,LARCOMBEA1,MORTONJ2,DAVIDGES2, JAMES A3,NOBLEP4 1Telethon Kids Institute, 2Department of Physiology, University of Alberta, COMBINING AN EPITHELIAL REPAIR FACTOR AND ANTI- Edmonton, Alberta, Canada; Department of Obstetrics and Gynecology, FIBROTICWITHACORTICOSTEROIDOFFERSOPTIMAL University of Alberta, Edmonton, Alberta, Canada, 3Department of Pulmonary TREATMENT FOR THE PATHOGENESIS OF ALLERGIC Physiology and Sleep Medicine, West Australian Sleep Disorders Research DISEASE INCORPORATING EPITHELIAL DAMAGE Institute, Sir Charles Gairdner Hospital and School of Medicine and Pharma- cology, University of Western Australia, WA, 6009, 4School of Anatomy, PATEL K1,SAMUELC1,ROYCES1,2 Physiology and Human Biology, University of Western Australia, WA, 6009 1Fibrosis Laboratory, Department of Pharmacology, Monash University, 2Respiratory Pharmacology Laboratory, Department of Pharmacology, Aim: Previous studies have shown that intrauterine growth restriction Monash University (IUGR) is associated with asthma in children and chronic lung disease in adults. The reasons for this association are unclear and, in general, prenatal Introduction/Aim: Airway epithelial damage is an important aetiology of links with asthma have been poorly studied. The aim of this study was to in- asthma. However, there are no treatments that target it or the ensuing airway vestigate the link between maternal hypoxia-induced IUGR and airway remodelling (AWR) and fibrosis that eventually cause airway obstruction/dys- hyperresponsiveness in adulthood. function. To address this, we superimposed naphthalene (NA)-induced epi- Methods: Pregnant female BALB/c mice were housed under hypoxic con- thelial damage onto the ovalbumin (OVA)-induced chronic allergic airways ditions (10.5% O2) from gestational days E11-E17.5. Following hypoxic expo- disease (AAD) murine model, which presented with the central features of sure, mice were returned to a normoxic environment (21% O2). A control asthma: airway inflammation (AI), AWR and airway hyperresponsiveness group of pregnant mice was housed under normoxic conditions throughout (AHR). We then evaluated the extent to which individual vs combination treat- pregnancy. Weights of female offspring were recorded weekly until 8 weeks ments that specifically targeted epithelial damage (trefoil factor-2, TFF2), fibro- of age at which point airway responsiveness to methacholine was assessed sis (serelaxin, RLN) or inflammation (dexamethasone, DEX) reversed the by the forced oscillation technique and thoracic gas volume by plethysmogra- pathogenesis of chronic AAD. phy. Weights and dimensions of lungs, heart and brains were recorded post- Methods: Following induction of the 9-week model of OVA-induced mortem. chronic AAD in 6- to 8-week-old female Balb/c mice, animals were i.p. admin- Results: Female offspring born to dams exposed to hypoxic conditions istered with NA on d64; then received daily i.n. administration of saline (vehi- were lighter at birth (n = 6) compared with control offspring (n =8;P =0.030), cle); RLN (0.8 mg/mL); TFF2 (0.5 mg/mL); DEX (0.5 mg/mL); RLN + TFF2; but not at 1 week (P = 0.095) or 8 weeks of age (P = 0.056). There were no dif- or RLN + TFF2 + DEX (n =7–8/group) from d67-74. On d75, lung function ferences in snout-vent length, abdominal circumference or weight of the brain, was assessed by invasive plethysmography, before lung tissue was isolated heart and lungs relative to body weight between groups at 8 weeks of age. for histological and biochemical analyses. A control group treated with sa- There was no difference in thoracic gas volume (P = 0.215). At 8 weeks, the line + corn oil (CO; vehicle for NA) was also included. airway resistance at baseline (P = 0.048) and after methacholine challenge Results: The OVA + NA group demonstrated significantly increased AI and was greater in offspring born to hypoxia-exposed dams (P=0.011) compared AWR (epithelial damage/thickness; subepithelial myofibroblast differentiation with controls. A similar effect was seen for peripheral lung mechanics after and collagen deposition) and significantly reduced dynamic compliance methacholine challenge (tissue damping, P = 0.039; tissue elastance, (all p < 0.01 vs. saline + CO). Compared to the individual treatments P = 0.030). evaluated, the combined effects of RLN + TFF2 + DEX demonstrated optimal Conclusion: Maternal hypoxia-induced IUGR offspring were smaller at protection against peribronchial inflammation score (1.28 ± 0.09 vs. 2.47 ± 0.12), birth but exhibited ‘catch up’ growth, as is often reported in clinical cohorts. Re- airway epithelial damage (3.03 ± 0.14 vs. 7.04 ± 0.36 thymic stromal tardation of foetal growth was associated with abnormal airway and lung me- lymphopoietin (TSLP)-stained cells/BM length), subepithelial collagen thickness chanics, including airway hyperresponsiveness. (24.59 ± 1.08 vs. 33.23 ± 0.88/BM length) and total lung collagen concentration Grant Support: NHMRC (1090888), WA Asthma Foundation. (2.58 ± 0.06% vs. 2.91 ± 0.06%) and normalized the OVA + NA-induced Declaration of Interest Statement: None. reductionindynamiccompliance(allp < 0.05 vs. OVA + NA group). Conclusion: Combining an epithelial repair factor and anti-fibrotic with a corticosteroid offers optimal treatment for the central components of chronic AAD/asthma. Grant Support: KPP: Monash MBio Postgraduate Discovery Scholarship; CSS: NHMRC Senior Research Fellowship.

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INHALED CORTICOSTEROIDS SUPPRESS INNATE AND INFLAMMATORY CELL SUBSETS ARE DECREASED IN ADAPTIVE ANTI-VIRAL IMMUNE RESPONSES IN THE PERIPHERAL BLOOD DURING AN ASTHMA FLARE-UP AIRWAYS JONES A2,MOKD1,READJ1, SERRALHA M1,HOLTB1,BIZZINTINOJ3, BARTLETT N1,2, SINGANAYAGAM A2,JOHNSTONS2 KHOO S3,RUETERK2,LAINGI3, GOLDBLATT J2, LESOUEF P2,KUSEL 1University of Newcastle, 2Imperial College London M1,SLYP4,HOLTP5, BOSCO A1, STRICKLAND D1 1Telethon Kids Institute, The University of Western Australia, Subiaco, Austra- Introduction/Aim: Emerging evidence suggests that glucocorticoids may lia, 2School of Paediatrics and Child Health, The University of Western Austra- impair innate anti-viral immune responses. Human studies have shown that lia, Princess Margaret Hospital, Subiaco, Australia, 3Telethon Kids Institute, oral prednisolone treatment prior to experimental rhinovirus (RV) challenge The University of Western Australia, Subiaco, Australia; School of Paediatrics in healthy subjects leads to increased viral titres in nasal lavage, and intrana- and Child Health, The University of Western Australia, Princess Margaret sal fluticasone administration during naturally occurring colds has been shown Hospital, Subiaco, Australia, 4Queensland Children’s Medical Research Insti- to be associated with prolonged virus shedding. To date, no studies have pro- tute, The University of Queensland, Brisbane, Australia, 5Telethon Kids Insti- vided a thorough analysis of the effects of inhaled corticosteroids (ICS) on in- tute, The University of Western Australia, Subiaco, Australia; Queensland nate and adaptive anti-viral responses during RV infection, the commonest Children’s Medical Research Institute, The University of Queensland, Bris- cause of acute asthma exacerbations. The aim of this study was therefore bane, Australia to evaluate the effects of the commonly used inhaled ICS fluticasone propionate (FP) on airway host-defence against rhinovirus infection using mouse Introduction/Aim: Severe lower respiratory viral infections cause acute vi- models. ral bronchiolitis in infancy and are a major risk factor for the pathogenesis of Methods: Mice were treated intranasally (i.n.) with FP (0.1 mg/kg to 1 mg/ asthma later in life. The immune system of infants is in a transient state of func- kg) 1 h prior to infection with RV. In some experiments, mice were additionally tional immaturity relative to adults. Thus, findings in adults cannot be extrapo- treated 1 h after infection with recombinant IFNb protein. Viral load and pulmo- lated to young children. Given that maturation of immunological function in nary inflammation was assessed by qPCR, ELISA, differentially stained early life can have a major impact on risk for infection and development of cytospin and flow cytometry. asthma-related traits, detailed studies based on defined age groups will be es- Results: FP suppressed expression of type-1 and type III IFN during RV in- sential. At present, our understanding of how antiviral responses change from fection. This was associated with reduced expression of interferon-stimulated infancy to older children is limited. Hence, a systematic study is required of the gene (ISG)s OAS1, Viperin and PKR. Anti-viral cellular responses were also cellular mechanisms underlying acute viral respiratory illnesses from infants inhibited: we observed reduced numbers of total and activated NK cells in with bronchiolitis through to school-age children with asthma. The aim of this BAL of mice treated with FP. Consistent with this suppression of anti-viral im- study is to investigate the cellular immune responses in peripheral blood sam- munity, we also observed impaired virus control and increased airway mucus ples collected from children during an acute asthma flare-up. production. FP administration suppressed production of RV specific IgG1 and Methods: Peripheral blood mononuclear cells (PBMC) were sampled from IgG2a antibodies in serum at day 14 post-challenge. Neutralization of RV1B children aged 9 ± 2.3 (mean ± SD) years (n = 21 pairs) during an acute cytopathic effect was also reduced in sera from infected mice treated with asthma flare-up (acute visit) and at 6–8 weeks following recovery (convales- FP. Treatment with recombinant interferon-beta reconstituted innate anti-viral cent visit). Healthy age-matched controls were included for baseline compar- responses suppressed by FP and restored virus control in the airways in mice. ison. Multiparametric flow cytometry (14-colours) was utilized to quantify Conclusion: We have demonstrated that the commonly prescribed in- myeloid and lymphoid cell subsets. Analysis of variance was assessed with haled ICS fluticasone propionate suppressed innate and adaptive anti-viral a Wilcoxon test for paired comparisons/Kruskal–Wallis test for unpaired immune responses leading to effects which may potentially be detrimental in comparisons. the context of virus-induced exacerbation of asthma or COPD. Results: The data showed a significant decrease in inflammatory cell sub- Grant Support: Wellcome Trust Clinical Research Training Fellowship, sets in PBMC during an acute episode of asthma, including plasmacytoid den- MRC, ERC and Asthma UK. dritic cells (p < 0.0001), conventional dendritic cells (p < 0.05), basophils (p < 0.001) and T cells (p < 0.001). High affinity IgE receptor (FcεRIα)was significantly lower during the acute episode in DC subsets. Conclusion: An asthma flare-up is associated with significant modulation of immune cell populations in peripheral blood. Grant Support: The PhD project is funded by an APA/UWA-safety net scholarship and NHMRC grant (APP1047663).

TO 029 TO 030

AIRWAY SMOOTH MUSCLE TONE INCREASES WITH AGE PLASMA CATHELICIDIN AND VITAMIN D CHANGES IN AND REDUCES BRONCHIAL COLLAPSIBILITY IN AN OVINE RELATION TO RESPIRATORY VIRUSES IN CHILDREN DEVELOPMENTAL MODEL PRESENTING WITH ACUTE WHEEZE

CHANG A, SORENSEN N, AHMADI-NOORBAKHSH S, PILLOW J, NOBLE P OO S1,2, FRANKS K1,3,KHOOS1,3,COXD1,CHIDLOWG4, WEEKE L1, The University of Western Australia PRASTANTI F1,3, EVERARD J1,3, BOCHKOV Y5,BORLANDM1,6, GORMAN S3,CLARKEM9,GERNJ5, GOLDBLATT J1,7,LAINGI1,3,SMITHD1,4,8, Introduction: Airway disease presents both early and late in life. Knowl- BIZZINTINO J1,3,LESOUEFP1,2 edge on how the mechanical properties of airways change through the natural 1School of Paediatrics and Child Health, Faculty of Medicine, Dentistry and course of life is important to better understand mechanisms producing abnor- Health Sciences, University of Western Australia, Perth, Australia, 2Respira- mal airway function. The present study tracked changes in the mechanical tory Department, Princess Margaret Hospital for Children, Perth, Western properties of bronchi from late gestation to adulthood using an ovine develop- Australia, 3Telethon Kids Institute, University of Western Australia, Perth, Aus- mental model. tralia, 4PathWest Laboratory Medicine WA, Perth, Australia, 5Department of Methods: Foetal (135–140 d gestation, n = 5), four month (n = 4), one year Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA, (n = 7) and five year sheep (n = 6) were studied. Following euthanasia, a bron- 6Emergency Department, Princess Margaret Hospital for Children, Perth, chial segment and ring were dissected and mounted in organ bath chambers. Australia, 7Genetic Services and Familial Cancer Program of WA, King Airway narrowing capacity (% volume) to acetylcholine was measured in bron- Edward Memorial Hospital, Perth, Australia, 8School of Pathology and Labo- chial segments and force (g) in bronchial rings. Collapsibility (pressure to clo- ratory Medicine, Faculty of Medicine, Dentistry and Health Sciences, Univer- sure) was determined before and after relaxation to theophylline or contraction sity of Western Australia, Perth, Australia, 9UWA Centre of Metabolomics, to acetylcholine. Passive inflationary compliance (0–20 cmH2O) was mea- University of Western Australia, Perth, WA sured after theophylline. Results: Collapsibility of foetal bronchi was greater than four month Introduction/Aim: Vitamin D (25(OH)D3) deficiency has been associated (P < 0.05), one year (P < 0.01) and five year sheep (P < 0.001). Collapsibility with asthma exacerbations, the majority of which are associated with respira- was reduced in response to acetylcholine in all age groups (P < 0.0001) and tory viruses, especially rhinovirus (RV). 25(OH)D3 levels influence the expres- increased in response to theophylline in one year (P < 0.01) and five year sion of cathelicidin (LL-37), an innate immune system protein with pleiotropic sheep (P < 0.001), but not in younger animals. Airway narrowing capacity effects including direct antibacterial and antiviral activity. Our aim is to com- and force was comparable between age groups. Compliance was reduced pare plasma LL-37 and 25(OH)D3 between wheezing children and non- in one year sheep compared with foetal lambs (P < 0.05), but there were no wheezing controls to determine whether these influence susceptibility to respi- other differences between groups. ratory viruses including rhinovirus species A and C (RV-A, RV-C). Conclusion: Active and passive properties of the airway are age depen- Methods: Cases (n = 186) were children aged 0–16 years recruited with an dent. Early development reduces the collapsibility of bronchi which likely re- acute wheezing illness of which 40 were followed up more than 6 weeks later flects structural maturation. The airway stiffens further later in life following when well. Controls (n = 109) were children without wheeze. At each visit, na- the development of intrinsic airway smooth muscle tone. sal specimens were tested for common respiratory viruses including RV spe- Grant Support: NHMRC (1077791, 1057759 and 1045824). cies, and plasma 25(OH)D3 was measured using liquid chromatography– Declaration of Interest Statement: None. mass spectrometry and LL-37 using a commercial ELISA kit. Length of stay was used to indicate clinical severity. Results: LL-37 was lower in all cases compared with all controls (geometric mean (GM) 56.01 vs 76.21 ng/mL, p = 0.002). GM of LL-37 was also lower in cases with RV-A (61.66 ng/mL, p = 0.01), RV-C (60.81 ng/mL, p < 0.001) and RSV (41.02 ng/mL, p < 0.001), compared with controls without viruses detected (83.36 ng/mL). Also, LL-37 was lower in these cases versus similarly infected controls (RV-A 90.78 ng/mL, p = 0.031, RV-C 97.5, p = 0.019, RSV 77.62, p = 0.003). At follow-up, LL-37 levels tended to increase, but only those that were initially RSV positive and virus negative at follow up showed a significant mean difference (57.74 ng/mL, p = 0.015). Lower LL-37 correlated with longer length of stay (r = 0-.225, p = 0.02). Vitamin D levels were similar in both cases (61.03 nmol/L) and controls (65.26 nmol/L, p = 0.104) and did not correlate with LL-37. Conclusions: Plasma LL-37 levels are lower in acute wheeze with RV and RSV and were associated with increasing severity. These findings suggest differences in innate immunity to viruses in children that wheeze. Grant Support: NHMRC, PMH Foundation Seeding Grant, J. B. is supported by a TSANZ/Astrazeneca respiratory research fellowship; S. O. is supported by PMH Foundation Clinical Fellowship.

TO 032 Cell Biology/Immunology 2 Oral Presentations

DETERMINING THE FUNDAMENTALS IN EPITHELIAL BARRIER INTEGRITY AND FUNCTION IN PAEDIATRIC ASTHMA TO 031 LOOI K1,2, BUCKLEY A3,RIGBYP3, GARRATT L1,2, IOSIFIDIS T1,4, LANNIGAN F4,5,KNIGHTD6,ZOSKYG7,LARCOMBEA2,LINGK2, NEONATAL PNEUMOCOCCAL COLONIZATION CAUSED BY MARTINOVICH K2, KICIC-STARCEVICH E2,SHAWN2,SUTANTOE1,2,8, INFLUENZA A VIRAL INFECTION ALTERS LUNG FUNCTION IN KICIC A1,2,4,8, STICK S1,2,4,8 ADULT MICE 1School of Paediatrics and Child Health, University of Western Australia, 2Telethon Kids Institute, University of Western Australia, 3Centre for Micros- 4 FITZPATRICK M1,ROYCES3, LANGENBACH S1,READINGP2,WIJBURG copy, Characterisation and Analysis, University of Western Australia, Centre 2 1 1 3 4 for Cell Therapy and Regenerative Medicine, University of Western Australia, O ,ANDERSONG,STEWARTA ,BOURKEJ,BOZINOVSKIS 5 6 1Lung Health Research Centre, Dept Pharmacology & Therapeutics, Univer- School of Medicine, Notre Dame University, School of Biomedical Sciences 2 and Pharmacy, University of Newcastle, 7Faculty of Health, University of Tas- sity of Melbourne, VIC, Australia, Peter Doherty Institute, Dept Microbiology 8 & Immunology, University of Melbourne, VIC, Australia, 3Dept Pharmacology, mania, Department of Respiratory Medicine, Princess Margaret Hospital for Monash University, VIC, Australia, 4RMIT University, School of Health Children Sciences and Health Innovations Research Institute, VIC, Australia Introduction/Aim: Tight junctions (TJ) provide a barrier against external in- Introduction/Aim: A developmental window of susceptibility exists in early sults. Despite TJs being extensively assessed in general terms, few studies life where lower respiratory tract viral infections can contribute to airway hyper- have directly addressed the consequence on barrier function following disas- responsiveness (AHR) that persists into adulthood. Viruses can facilitate sembly of TJ protein post-human rhinovirus (HRV) infection. This study aimed pneumococcal carriage in neonates, and there is also evidence that coloniz- to assess TJ expression and barrier function prior and post-HRV infection in ing bacteria may increase risk of developing airway dysfunction. Our aim cultures of both healthy and asthmatic epithelium. was to assess lung function, structure and immune profile following early life Methods: Healthy and asthmatic airway epithelial cells, obtained and cul- exposure to infection. tured as previously described (Kicic et al. 2006) were differentiated into ALI Methods: C57Bl/6 infant mice were infected intranasally at 5 days of age and subsequently infected with HRV-1B over 24 h. TJ gene expression was with S. pneumonia EF3030 (SP, 2X103 CFU/mL in saline, or vehicle) and at assessed via qPCR, barrier integrity measured by protein expression of 12 days of age co-infected with influenza A virus (IAV, 7000 PFU/mL HKx31 claudin-1, occludin and zonula occluden-1 (ZO-1) via immunocytochemistry in saline, or vehicle). Outcomes were assessed at 6–8 weeks of age including (ICC), in-cell western (ICW) and confocal microscopy. Barrier function was assessment of bacterial carriage, lung function and histology. assessed via transepithelial electrical resistance (RT) measurement and a Results: Neonatal co-infection resulted in persistent nasopharyngeal coloni- permeability assay. zation and a significant increase in airway resistance and hysteresivity Results: TJ gene expression was significantly increased in asthmatic epi- in vivo. AHR was not associated with increased airway smooth muscle or gob- thelium for claudin-1 and occludin, while ZO-1 was not significantly different let cells and was not maintained in lung slices in vitro. Epithelial integrity compared to healthy control. Protein expression for claudin-1, occludin and markers were unchanged in PCR analysis. ZO-1 via ICC was markedly reduced in asthmatics compared to healthy con- Conclusion: Neonatal co-infection led to persistent bacterial nasal car- trols. Assessment of all 3 TJ protein expressions via ICW corroborated ICC riage and AHR that was not associated with structural changes in the airway findings. Greater effect on TJ disassembly was observed within the asthmatic muscle or mucosal epithelial abnormalities. Furthermore, airway heterogene- epithelium post-infection, concomitant with marked increase in transepithelial ity caused by IAV infection was not prevented by co-infection with SP. Future permeability. Assessment of occludin and ZO-1 protein expression via confo- studies will determine whether co-infection will be protective or detrimental to cal microscopy corroborated ICW findings. Greater effect on TJ disassembly development of an asthma-like phenotype following chronic allergen was observed within asthmatic ALI epithelium post-infection concomitant with challenge. significant decrease in RT and marked increase in permeability. Grant Support: NHMRC. Conclusions: This study demonstrates significant differences in basal membrane TJ protein expression between healthy and asthmatic epithelial cells, suggesting intrinsic differences between healthy and mild-asthmatic epithelium. Post-HRV infection, an exaggerated disassembly in the asthmatic epithelial cells, concomitant with increased permeability suggests elevated trafficking of small-sized aeroallergens into the sub-epithelial space, contributing to asthma exacerbations. Grant Support: NHMRC, APA Scholarship, UWA, PMH Foundation Top- up Scholarship. Prize eligibility: Ann Woolcock Young Investigator Award, Janet Elder In- ternational Travel Award, Japanese Respiratory Society Early Career Devel- opment Award, Oral Prize. Declaration of interest: I declare no conflict of interest. References: Kicic A, Sutanto EN, Stevens PT, Knight DA, Stick SM. Intrin- sic Biochemical and Functional Differences in Bronchial Epithelial Cells of Children with Asthma. American Journal of Respiratory and Critical Care Med- icine. 2006;174(10):1110-8

TO 033 TO 034

EARLY-LIFE RESPIRATORY BACTERIAL INFECTION- REGULATION OF LUNG MATURATION BY PROLYL INDUCED CHRONIC LUNG DISEASE IS DRIVEN BY A NOVEL HYDROXYLASE DOMAIN (PHD) INHIBITION IN THE LUNG OF TLR2/IL-13/MIR-21/PI3K SIGNALLING PATHWAY THE NORMALLY GROWN AND PLACENTALLY RESTRICTED FOETUS IN LATE GESTATION STARKEY M, NGUYEN D, KIM R, HAW T, NAIR P, ESSILFIE A, HORVAT J, HANSBRO P ORGEIG S, MCGILLICK E, MORRISON J Hunter Medical Research Insitute and University of Newcastle University of South Australia

Introduction/Aim: There is a critical window in early-life where the lung Introduction/Aim: Placental restriction (PR) in sheep results in intrauterine and immune system are still maturing and this increases susceptibility to infec- growth restriction, chronic hypoxemia and reduced surfactant maturation.1 Al- tion. Indeed, severe respiratory infections in early-life are a risk factor for the tered hypoxia signalling by increased prolyl hydroxylase domain (PHD) ex- development of chronic lung diseases. The aim of this study was to identify pression in the PR foetal lung may be responsible for reduced surfactant.2 the mechanisms involved. To understand the role of PHDs in regulating surfactant maturation, we evalu- À À À À Methods: / / À À NeonatalÀ À wild-type (WT), TLR2 deficient ( ), IL-13 , ated the effect of administration of the PHD inhibitor dimethyloxalylglycine MyD88 / and STAT6 / mice were infected with the natural mouse patho- (DMOG) in the lung of Control and PR foetuses. gen Chlamydia muridarum, as a model of moderate-to-severe respiratory bac- Methods: PR was induced by carunclectomy (n = 13). At 131 and 132d terial infection in early-life. In some experiments, WT mice were treated with gestation (term = 150 ± 3d), foetuses received a bolus of saline (Control (C), miR-21-specific antagomirs, the pan-PI3K inhibitor LY294002, or relevant ve- 11; PR, 7) or PHD inhibitor (C + DMOG, 8; PR + DMOG, 6) into the lung via hicle controls during early-life infection. The impact of these specific immune a non-obstructive tracheal catheter. Expression of genes regulating surfactant molecules on early-life bacterial infection-induced impairment of lung function maturation (surfactant proteins SFTP-A, -B, -C and -D; surfactant lipid regula- and alveolar structure were assessed. tory genes PCYT1A, LPCAT, LAMP3 and ABCA3) were quantified in lung tis- Results: Neonatal Chlamydia respiratory infection increased TLR2, IL-13- sue at 133d by qRT-PCR. Total phosphatidylcholine (PC) was measured in receptor, miR-21 and PI3K expression and/or activity in the lung. TLR2 signal- lung lavage. Numerical density of SFTP-B positive cells in lung tissue was de- ling induced IL-13-receptor expression, IL-13 signalling induced miR-21 ex- termined by point counting. Data were analysed by one-way ANOVA with pression and miR-21 increased PI3K activity. TLR2 signalling also Duncan post-hoc test (P < 0.05). increased the number of IL-13+ type-2 innate lymphoid cells in the lung. Results: PR reduced PaO2, O2 saturation and foetal weight compared À À À À TLR2 / and IL-13 / mice were protected against infection-induced persis- with C. There was reduced expression of SFTP-A, -B, -C, regulator of surfac- tent airway hyperresponsiveness (AHR), but not emphysema-like alveolar en- tant lipid synthesis LPCAT and total lavage PC in the C + DMOG and PR com- largement. This TLR2/IL-13 mediated phenotype was independent of MyD88, pared with C foetuses. There was reduced expression of surfactant lipid but dependent on STAT6 signalling. Specific targeting of miR-21 prevented in- regulatory genes PCYT1A, LAMP3 and ABCA3 in C + DMOG foetuses com- fection-induced AHR but not alveolar enlargement. Pan-PI3K inhibition did not pared with C and PR. There was no further effect of PR + DMOG on expres- affect AHR, but protected against alveolar enlargement. Interestingly, early- sion of genes compared with PR alone. There was no effect of either PR or life infection-induced persistent AHR was insensitive to steroid treatment DMOG on the numerical density of SFTP-B positive cells in the foetal lung. and increased the severity of emphysema following cigarette smoke exposure Conclusion: DMOG mimics the effect of PR, reducing surfactant matura- in adulthood. tion in the C foetus. There was no cumulative effect of PR + DMOG, suggest- Conclusions: Early-life respiratory bacterial infections increase TLR2, IL- ing a maximal down-regulation of the surfactant system following chronic 13, miR-21 and PI3K responses that promote the development of chronic lung hypoxemia in the PR foetus. disease in later-life. This study identifies a novel signalling network that may References: 1. Orgeig et al., Am. J. Physiol., 2010, 298: L575-L583. 2. be targeted for the prevention of the long-term deleterious effects of early-life Orgeig et al., Am. J. Physiol., 2015, 309: L84-L97 infection on lung function and structure. Grant Support: Supported by the NHMRC of Australia. Grant Support: NHMRC. Conflict of interest: None.

TO 035 TO 036

THE NEW KID ON THE BLOCK: E-CIGARETTES CAN CAUSE ENDOSOMAL NOX2 OXIDASE EXACERBATES INFLUENZA A DAMAGE TO AIRWAY CELLS AND CAUSE AIRWAY VIRAL PATHOGENICITY. MACROPHAGE DYSFUNCTION SELEMIDIS S1,TOE1, LUONG R1, HALLS M2,PORTERC2,QUACHT2, WEEN M1,2, HODGE G1.2, REYNOLDS P1,2,HODGES1,2 READING P3,BROOKSD4,DRUMMONDG1,STARKEYM5,KINGP6, 1Hanson Institute and department of Thoracic Medicine, Royal Adelaide Hos- BOZINOVSKI S7, VLAHOS R7 pital, 2School of Medicine, University of Adelaide 1Monash University, 2Monash University, 3The University Of Melbourne, 4Uni- versity of South Australia, 5The University of Newcastle, 6Monash Medical Introduction/Aim: E-cigarettes are perceived as being harmless; however, Centre, Monash University, 7RMIT there is a lack of information regarding their safety. New data suggest that E-cigarettes are not only able to cause damage to the user, but they also re- Endosomal NOX2 oxidase exacerbates influenza A viral pathogenicity. lease particles and chemicals other than water into the environment, creating Introduction/Aim: Reactive oxygen species (ROS) are crucial for the elim- concern for ‘second-hand vapour’. We previously established that cigarette ination of pathogenic bacteria, but the impact of ROS on viral pathogenicity is smoke caused increased apoptosis of bronchial epithelial cells and defective yet to be clearly defined. Our aim is to determine (1) the site of subcellular alveolar phagocytosis of these cells (‘efferocytosis’) and airway bacteria. We ROS generation, (2) the identity of the enzymes that generate ROS and (3) hypothesize that E-liquids (± nicotine) cause changes to airway cells similar the impact of ROS on the pathogenesis of influenza A virus infection in vivo. to those seen in response to cigarette smoke. Methods: Confocal fluorescence microscopy was used to assess the sub- Methods: THP-1 macrophages and 16HBE bronchial epithelial cells were cellular distribution of viruses, Toll-like receptors (TLRs) and NOX enzymes, stimulated with media (control) and various concentrations/combinations of and to assess endosomal superoxide production in human and mouse macro- the E-cigarette system including E-liquid, nicotine (18 mg/mL), vegetable glyc- phages that were infected with various ssRNA viruses (influenza A virus, HIV, erine (VG), propylene glycol (PG), with cigarette smoke extract and paclitaxel Dengue, rhinovirus, respiratory synctitial virus, human parainfluenza virus and as a positive apoptosis controls. Macrophage phagocytosis of NTHi and apo- human metapneumovirus), dsRNA viruses (rotavirus) and dsDNA viruses ptotic epithelial cells and macrophage recognition molecules were assessed (herpes simplex 2 and vaccinia virus). Mice (C57Bl/6) were infected intrana- by flow cytometry. Epithelial cell viability was measured by flow cytometric sally with influenza A virus (Hong Kong X-31 strain, 105 PFUs/mouse) for as- analysis of annexin-V and 7AAD and western blot analysis of caspase 3 sessments of airways inflammation, viral titers, cytokine expression and and PARP cleavage. IL-1β (a pro-inflammatory cytokine that correlates with serum antibody levels. Site-directed mutagenesis was used to mutate cyste- COPD severity) was measured in macrophages by immunohistochemistry. ine residues to alanine on TLR7 for assessments of oxidatively modified Results: The effects of E-cigarettes on macrophage function were receptor. assessed. Phagocytosis of NTHi was significantly decreased by E-liquid, Results: NOX2 oxidase co-located with virus and TLR7 in early and E-liquid + nicotine (59%, 33%) and efferocytosis was significantly de- endosomes, providing a spatially targeted platform for ROS production that creased by E-liquid, nicotine and E-liquid + nicotine (28%, 33%, and 35% operated within minutes after the internalization of the single-stranded RNA vs. control). Epithelial cell apoptosis was significantly increased by E-liquid, and DNA viruses into endocytic compartments. NOX2 oxidase activation E-liquid + nicotine, PG, and PG + VG. IL-1β was increased in preliminary ex- was critically dependent on endosomal acidification and the engagement of periments where macrophages were exposed to E-liquid and E-liquid TLR7 for ssRNA viruses or TLR9 for DNA viruses. NOX2-dependent +nicotine. endosomal H2O2 caused modification of crucial cysteine residues on the Conclusions: E-cigarette components cause damage to macrophage ectodomain of TLR7, resulting in suppression of innate anti-viral cytokine ex- function, epithelial cell viability and pro-inflammatory cytokine synthesis, po- pression. Inhibition of NOX2 by genetic deletion or by novel endosome tentially contributing to chronic lung inflammation. Our data provide important targeted pharmacological inhibitors of NOX2 resulted in a significant suppres- information on the harmful effects of E-cigarettes for health providers, policy sion in airways inflammation and viral titers following influenza A virus makers and general public, especially young people who engage in vaping infection. for social reasons. Conclusion: Viruses activate endosomal NOX2 oxidase, which sup- presses fundamental components of viral immunity, and this has major implications for the treatment of respiratory viral infections.

TO 038 Paediatric 1 Oral Presentations

CAN RISK FACTORS FOR COPD BE TRACED BACK TO INFANCY? TO 037 OWENS L1,LAINGI1,2,ZHANGG1,3, LE SOUEF P1 1University of Western Australia, 2Telethon Kids Institute, 3Curtin University

CHILDHOOD INTERSTITIAL LUNG DISEASE (CHILD) IN Introduction/Aim: Reduced FEV1/FVC is the cornerstone of COPD diag- IMMUNOCOMPETENT CHILDREN IN AUSTRALIA AND NEW nosis. Therefore, a reduction in early adulthood, followed by the normal natu- ZEALAND: A 10 YEAR REVIEW ral decline is a significant risk factor(1). COPD has its origins during childhood SADDI V1, BEGGS S2, BENNETTS B3,4,HARRISONJ5,HIMEN6,4,KAPUR (2–4). However, evidence from birth cohorts followed into adulthood, allowing N7,LIPPSETTJ8, NOGEE L9,PHUA10,4, SURESH S7,SCHULTZA11, these risk factors to be tracked from infancy, is minimal. We hypothesized that SELVADURAI H10,4,SHERRARDS11,STRACHANR1,VYASJ12, risk factors for reduced FEV1/FVC in adults could be traced back to in utero ZURYNSKI Y6,JAFFEA1,13 and early life insults. 1Department of Respiratory Medicine, Sydney Children’s Hospital, Randwick, Methods: The Perth Infant Asthma Follow-up study is a longitudinal birth NSW 2031, Sydney, Australia, 2Department of Paediatrics, Royal Hobart Hos- cohort of 253 infants recruited antenatally with detailed respiratory assess- pital, Hobart, Tasmania 7000, Australia, 3Department of Molecular Genetics, ments including lung function, airway responsiveness testing, questionnaires The Children’s Hospital at Westmead, NSW 2145, Sydney, Australia, 4Disci- and skin prick testing at 1, 6 and 12 months and 6, 11, 18 and 24 years of age. pline of Paediatrics and Child Health, Sydney Medical School, The University Linear regression identified predictive factors of an FEV1/FVC ratio in the low- of Sydney, Sydney, NSW 2006, Australia, 5Department of Respiratory Medi- est quartile in young adults. cine, The Children’s Hospital, Melbourne, Victoria 3052, Australia, 6Australian Results: Infant lung function at 1, 6 and 12 months of age was predictive of Paediatric Surveillance Unit, Kids Research Institute, Sydney, NSW 2145, FEV1/FVC at 24 years (standardized B = 0.189, p = 0.048; B = 0.223, Australia, 7Department of Respiratory Medicine, Lady Cilento Children’sHos- p = 0.025; and B = 0.215, p = 0.045, respectively). Predictive factors for an pital, Brisbane, Queensland 4101, Australia, 8Department of Anatomical FEV1/FVC ratio in the lowest quartile at 24 years were parental asthma and Pathology, SA Pathology, Women’sandChildren’s Hospital, North Adelaide, current asthma at 6 and 11 years (OR = 4.9, p = 0.001; OR = 5.2, p = 0.015; South Australia 5154, Australia, 9Department of Neonatology, Johns Hopkins OR = 4.8, p = 0.006). Exclusive breastfeeding for 3 months was protective Hospital, Baltimore, MD 21287, USA, 10Department of Respiratory Medicine, (OR = 0.27, p = 0.016). Non-significant factors included birthweight, maternal The Children’s Hospital at Westmead, NSW 2145, Sydney, Australia smoking during pregnancy and a history of asthma before 6 years (OR = 1.15, p =0.772;OR=1.1,p = 0.84; OR = 2.6, p = 0.071). Introduction/Aim: Childhood Interstitial Lung Disease (chILD) is a rare Conclusions: We confirmed that lung function tracks from infancy through heterogeneous group of respiratory disorders. The aim of this study was to re- to early adulthood. Early asthma, which is resolved by 6 years of age is not port the experience of chILD in Australasia, calculate its prevalence and as- predictive of lower FEV1/FVC at 24 years. However, persistant disease sess the diagnoses in the context of a proposed classification system. throughout school age is predictive, suggesting a crucial difference in pheno- Method: Paediatric respiratory physicians in Australia and New Zealand type. Breastfeeding in early infancy is a modifiable protective factor, which involved in the care of chILD patients aged 0–18 years completed a question- may be promoted particularly in those most at risk, such as infants with paren- naire on demographics, clinical features and outcomes between 2003 and tal asthma. 2013. Diagnoses were compared to the classification system proposed by Grant Support: NHMRC grant, the Asthma Foundation of Western Austra- the chILD Research Network, USA. Prevalence was calculated using age- lia PhD top-up scholarship and a PMH Foundation seeding grant. specific population estimates for the median childhood population in 2008. Declaration of Interest: The authors have no conflicts of interest. Results: One hundred eight cases were identified equating to a prevalence of 1.7 cases/million for children aged 0–18 years. The <2 group comprised 66 REFERENCES children, median age 0.50 years (0.01–1.92); the ≥2 year group comprised 40 1. Lange P, Celli B, Agustí A, Boje Jensen G, Divo M, Faner R, et al. Lung- children aged 8.2 years (2.0–18.0). The commonest diagnosis was neuroen- Function Trajectories Leading to Chronic Obstructive Pulmonary Disease. docrine cell hyperplasia of infancy (n = 15). No specific diagnosis was possible New England Journal of Medicine. 2015;373(2):111-22. in 20 (18%) patients. The disease was unclassifiable in 17 (26%) of <2year 2. Tagiyeva N, Devereux G, Fielding S, Turner S, Douglas G. Outcomes of olds and 4 (10%) in the ≥2 year group. Forty-five percent of the older group Childhood Asthma and Wheezy Bronchitis - a 50-year Cohort Study. Ameri- was classified in the systemic disease category. There was a heterogeneous can journal of respiratory and critical care medicine. 2015. approach to management with good outcome in 79.3% of patients. Mortality 3. Svanes C, Sunyer J, Plana E, Dharmage S, Heinrich J, Jarvis D, et al.Early was 6.9% in the study population. life origins of chronic obstructive pulmonary disease. Thorax. 2010;65(1): Conclusion: chILD is rare in Australasia. This study demonstrates varia- 14-20. tion in management across Australasia; however, general outcome is 4. Stocks J, Sonnappa S. Early life influences on the development of chronic favourable. The proposed chILD classification system can be applied to both obstructive pulmonary disease. Therapeutic advances in respiratory disease. children under 2 and over 2 years of age, but the latter group needs expansion 2013;7(3):161–73. as many of the older patients had chILD in the context of systemic disease. This is the first study to report Australasian data on chILD and joins the global collaborative efforts aimed at improving understanding of this rare group of disorders. Key words: Australia, classification, childhood, interstitial, New Zealand, prevalence Grant Support: APSU Chronic Diseases grant from the Commonwealth; US National Institutes for Health.

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IL-1RA PROTECTS AGAINST IMPAIRED ALVEOLAR HEALTHY LUNGS STUDY: CAN AN INTENSIVE PRIMARY DEVELOPMENT BUT NOT AIRWAY HYPERRESPONSIVENESS CARE PROGRAMME IN HIGH RISK INFANTS REDUCE IN A MOUSE MODEL OF BRONCHOPULMONARY DYSPLASIA RESPIRATORY MORBIDITY TWO YEARS AFTER ADMISSION WITH SEVERE LRI BOURKE J1,ROYCES1, LAMANNA E1, LAM M1,DONOVANC1,BUIC2, NOLD M2,NOLDC2 BYRNES C1,2, TRENHOLME A1,3,AISHH4, HOARE K4,HIGHAMJ4, 1Department of Pharmacology, Biomedicine Discovery Institute, Monash METCALFE R2,MCINTOSHC3,4, VOGEL A4, LAWRENCE S3,4,STEWARTJ5 University, 2Hudson Institute of Medical Research 1University of Auckland, 2Starship Children’s Hospital, 3KidzFirst Hospital, Counties Manukau District Health Board, 4Centre for Clinical Research and 5 Introduction/Aims: Higher survival rates of extremely preterm babies are Effective Practics, School of Population Health associated with an increasing incidence of bronchopulmonary dysplasia (BPD) and multiple complications including airway hyperresponsiveness Introduction/Aim: NZ children have high rates of lower respiratory infec- (AHR) and asthma. In a mouse BPD model combining perinatal inflammation tions (LRI) and bronchiectasis (Bx), with concern that one precedes the other. and hyperoxia, interleukin-1α (IL-1α) was shown to be a major driver of im- Our pilot study reported 66% admitted with severe LRI had respiratory morbid- paired alveolar development (Nold et al., PNAS 2013). The aim of this study ity 1 year later. We hypothesized an intervention programme instituted follow- was to test the effects of the IL-1 receptor antagonist, IL-1Ra (Anakinra), in this ing admission would reduce respiratory morbidity at 2 year follow-up model, examining airway remodelling and contractile responses associated compared to usual community care (controls). with AHR. Methods: Four hundred South Auckland infants <2 years of age admitted Methods: Pregnant C57BL/6J dams received 150 μg/kg lipopolysaccha- with severe LRI were randomized to ‘intervention’ (n = 203) or ‘control’ ride or saline i.p. at 14 d gestation. Within 24 h of birth, pups were randomized (n = 197). Interventions were three monthly GP clinics, nursing and health to normoxic (N, 21% O2) or hyperoxic (H, 65% O2) conditions and treated worker support, dental, nutrition, immunization, smoking cessation, skin daily for 28 days with IL-1Ra or saline. Lung sections were analysed for alve- health and housing support. Standardized respiratory assessment with proto- olar changes, epithelial thickening, subepithelial collagen and expression of cols for wet cough and/or wheeze was instituted. Persistent symptoms and/or the contractile protein α-smooth muscle actin (α-SMA). Precision cut lung persistent chest xray (CXR) changes or other non-respiratory concerns lead to slices (PCLS) were prepared to visualize changes in intrapulmonary airway secondary care referral. All children were evaluated 24 months later by a pae- area to methacholine (MCh) by phase-contrast microscopy. diatrician blinded to randomization and past history at a time of parent-deter- Results: Hyperoxic mice developed a severe BPD-like lung disease (60% mined stable health. fewer alveoli, 4-fold increase in alveolar size). Epithelial thickness, Results: 165/203 (81%) intervention and 156/197 (79%) controls had an subepithelial collagen and α-SMA expression increased in airways following outcome visit 24 months post-admission. No significant difference for wet hyperoxia. MCh elicited contraction with similar potency in both groups cough in clinic (intervention 53 (32.3%), control 53 (34%), P = 0.87) or pres- (pEC50: N 7.4 ± 0.4, n = 6; H 7.2 ± 0.2, n = 7), but increased maximum follow- ence of clubbing/crackles (intervention 36 (21.8%), control 37 (23.7%), ing hyperoxia (% reduction in airway area: N 44 ± 10; H 89 ± 10; P < 0.05). IL- P = 0.75) was found. CXR was obtained in 294/321 with no significant differ- 1Ra treatment normalized alveolar development and reduced epithelial/ ence for focal change (intervention 25 (17.5%), control 37 (23.7%), subepithelial changes but did not prevent up-regulation of α-SMA or increased P = 0.85). No difference was observed in asthma or viral wheeze. In total, 15 contraction to MCh. were diagnosed with Bx by the final visit (4.8%), plus five referred at final Conclusions: This mouse model mimics key features of BPD, namely, in- review. creased alveolar disruption, airway fibrosis and AHR. IL-1Ra may be a novel Conclusion: Ongoing respiratory morbidity and/or significant CXR change treatment to prevent lung damage and remodelling in BPD; however, alterna- was evident 2 years after hospital admission for severe LRI. This was not im- tive therapeutic targets need to be identified to limit the increased airway con- pacted by intensive primary care follow-up within this time frame. traction and associated respiratory consequences in premature infants. Acknowledgements: HRC grant 10/510. No conflict of interests Grant Support: NHMRC. Declaration of Interest: None.

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ABILITY OF LUNG CLEARANCE INDEX TO MONITOR THE HIGHER LUNG CLEARANCE INDEX (LCI) REFLECTS OTHER PROGRESSION OF EARLY LUNG DISEASE IN CHILDREN MEASURES OF CLINICAL RESPIRATORY STATUS IN CYSTIC WITH CYSTIC FIBROSIS FIBROSIS (CF) PRESCHOOL CHILDREN

FOONG R1,RAMSEYK1,2, HARPER A1,TURKOVICL1, ROSENOW T1, HARDAKER K1,HULMEK2,GUSTAFSSONP3,COOPERP1,FITZGER- SKORIC B3,4, RANGANATHAN S3,4,STICKS1,5,HALLG1 ALD D1,2, SELVADURAI H1,2, ROBINSON P1,2 1Telethon Kids Institute, University of Western Australia, WA, Australia, 2Cys- 1The Children’s Hospital at Westmead, Sydney Children’s Hospital Network, tic Fibrosis Research and Treatment Centre, University of North Carolina at NSW, Australia, 2Discipline of Paediatrics and Child Health, Sydney Medical Chapel Hill, North Carolina, USA, 3Royal Children’s Hospital, Victoria, Austra- School, University of Sydney, NSW, Australia, 3Department of Paediatrics, lia, 4Department of Respiratory Medicine, Murdoch Children’s Research Central Hospital, Skövde, Sweden Institute, Victoria, Australia, 5Department of Respiratory Medicine, Princess Margaret Hospital for Children, WA, Australia Introduction/Aim: Availability of robust commercial multiple breath nitrogen washout (MBNW) equipment offers improved feasibility for preschool lung Introduction/Aim: The lung clearance index (LCI) is a marker of ventilation function testing in cystic fibrosis (CF) clinics. Standardization of commercial inhomogeneity derived from the multiple breath washout technique. Cross- equipment and testing protocol in the preschool age range is the current focus sectional studies show that LCI is sensitive to detect the presence and extent of an ATS funded project. Clinical value of MBW in preschoolers is unclear. of structural lung disease, neutrophilic inflammation and infection in infants This study aimed to explore the relationship between lung clearance index and children with cystic fibrosis (CF). We aimed to determine if changes in (LCI) values in and other markers of clinical CF pulmonary disease. LCI can identify the progression of structural lung disease on chest computed Methods: Prospective screening of preschool CF subjects (aged tomography (CT) and extent of pulmonary infection and inflammation. 2–6 years) within a large tertiary paediatric CF clinic with commercial MBNW Methods: Repeated LCI measurements were obtained from 26 children equipment (Exhalyser D, Ecomedics). Facemask interface and equipment ad- with CF (aged 3 to 9 years) over a 12-month period. Measurements were per- aptation were used to fulfil dead space volume requirements for the preschool formed prior to the collection of bronchoalveolar lavage fluid (BAL) and chest age range. LCI reported as mean of three technically acceptable tests (1st ac- CT. Structural lung disease was assessed using the PRAGMA quantitative ceptable visit). Clinical data collected included demographics, medication use outcome measure. Neutrophil elastase (NE) and interleukin 8 (IL8) in BAL in the past 12 months, bacterial sputum isolates to date (haemophilus influ- were quantified by ELISA. Changes in LCI and CT, infection and inflammation enza, HI, staph aureus, SA and pseudomonas aeruginosa, PsA). Due to lack outcomes between repeated visits were assessed using mixed effects model. of preschool MBNW reference data, proportions were compared across two Results: Repeated matched MBW and chest CT data were available for 23 groups of LCI values: those above and below the median value (termed children, and matched MBW and BAL for 19 children. Increases in LCI were ‘higher’ and ‘lower’ LCI cohorts, respectively). significantly associated with progression of bronchiectasis (p = 0.005), air Results: Thirty-two out of forty-nine preschool children (2–6 years old, trapping (p = 0.044) and bronchial wall thickening (p =0.012).Therewereno 65%) screened to date: mean (SD) age 5.2 (1.2, range 3.2–6.9) years, 47% significant associations between change in LCI and the extent of NE and male, median (range) LCI 7.7(6.4–13.9). The higher LCI cohort (>7.7), vs. IL8. However, there was a greater increase in LCI in children that had NE pres- lower LCI cohort, had greater rates of medication use (regular dornase alfa ent in BAL at their second visit but not at their first visit, compared with children 75% vs. 31%, p = 0.032; regular hypertonic saline 88% vs. 69%, p = 0.39; pre- who had NE present at both visits. Similarly, increased LCI was associated vious IV antibiotic course 44% vs.19%, p = 0.25; total oral antibiotic use in the with the development of a respiratory infection not present in the previous visit. last 12 months 10.8 (6.8) vs. 7.6 (4.8) weeks; p = 0.10) and bacterial sputum Conclusion: LCI may be a sensitive tool to monitor the progression of isolates (any HI 94% vs.56%, p = 0.03; any SA 94% vs. 63%, p = 0.08; any structural lung disease and the development of lower respiratory tract inflam- PsA 44% vs. 19%, p0.25). mation and infection in young children with CF. Conclusion: In preschool children, higher LCI values reflected subjects Grant Support: US Cystic Fibrosis Foundation Award Number HALL14A0. with other measures of greater levels of pulmonary involvement (e.g. greater medication use and greater incidence of bacterial isolation). Grant Support: CF fundraising, CHW.

TO 044 Tobacco and Related Substances Oral Presentations

THE BARRIERS AND FACILITATORS TO EFFECTIVE USE OF A SMARTPHONE APPLICATION FOR SMOKING CESSATION BY HEALTH PROFESSIONALS AND SMOKERS TO 043 VAN AGTEREN J1,2,CARSONK1,2,3,JAYASINGHEH1,2,3,SMITHB1,2,3 1The Queen Elizabeth Hospital, 2Basil Hetzel Institute for Trasnlational Health ELECTRONIC CIGARETTE VAPOUR IMPAIRS LUNG Research, 3School of Medicine, Adelaide University DEVELOPMENT AND FUNCTION IN MICE Introduction/Aim: Our aim is to determine the facilitators and barriers for LARCOMBE A1,JANKAM1, BREDIN A2,BERRYL1,FRANKLINP3,4 the use of a smartphone app as a smoking cessation method by smokers 1Telethon Kids Institute, University of Western Australia, Subiaco, Western and health professionals (HP’s). Australia, Australia, 2Fluid Dynamics Research Group, Curtin University, Method: Qualitative interviews involving a focus group and semi-structured Perth, Western Australia, Australia, 3School of Population Health, M431, Uni- interviews were conducted with current and ex-smokers as well as HP’sattwo versity of Western Australia, Crawley, Western Australia, Australia, 4Environ- hospitals in South Australia. Audio recordings were taken, and transcripts mental Health Directorate, Public Health Division, Department of Health were typed verbatim. Data were coded and analysed by two independent researchers under thematic categories of the TRAINDIS model of interpersonal Introduction/Aim: Electronic cigarettes (e-cigarettes) heat and aerosolize behaviour using QSR NVivo version 10. a solution (containing nicotine/flavourings, and an excipient), producing a Results: Four current smokers and one ex-smoker took part in the focus- vapour which is inhaled. Due to their recent introduction, virtually no research group, whilst four senior respiratory specialists from two hospitals and one ad- has been conducted into their potential to impact health. This study aimed to vanced trainee were recruited (n = 1 male) for individual interviews. Both assess whether chronic exposure to e-cigarette vapour would impair lung groups placed high importance on (normative) feedback, ease-of-use, tailor- function in mice and to compare the severity of any impairments with mice ing, push notifications and credibility for use of the app. The focus group exposed to tobacco smoke. placed a high value on personal ability to quit, with low level of confidence in Methods: Female BALB/c mice were exposed to tobacco smoke, medical pharmacotherapy and professional counselling, a view supported by some ’ air or one of four different e-cigarette vapours from week 4 to week 12 of life. HP s who indicated low enthusiasm for the use of quitline and/or pharmaco- E-cigarettes varied depending on nicotine content (0 or 12 mg/mL) and the therapy among their patients. While both groups seemed interested in innova- ’ main excipient (propylene glycol or vegetable glycerin). Twenty-four hours tive approaches to smoking cessation, none of the HP s ever used or after the final exposure, we measured lung volume, lung mechanics, respon- recommended text-, internet- or smartphone-based tools for smoking cessa- siveness to methacholine (MCh) and pulmonary inflammation. We also tion. Lack of awareness of innovative approaches to smoking cessation was assessed the physico-chemical properties of the smoke and vapours. a recurrent theme in the HP interviews, despite an apparent enthusiasm of Results: Mice exposed to tobacco smoke or e-cigarette vapour containing the potential a smartphone app for smoking cessation has to offer. ’ nicotine showed impaired somatic growth. Tobacco smoke-exposed mice had Conclusions: The HP s limited awareness of innovative approaches to increased inflammation and were more responsive to MCh, compared with smoking cessation may indicate that more emphasis needs to be placed on controls. Mice exposed to e-cigarette vapour displayed a range of decrements informing the healthcare sector about the benefits of new technology, or that in parenchymal lung function. Mice exposed to vegetable glycerin-based there is a lack of evidence to support this technology in clinical practice. Re- vapours were hyper-responsive to MCh regardless of nicotine content. sults from this trial will be used to develop the first social network-based E-cigarette vapour did not elicit pulmonary inflammation or alter lung smartphone app for smoking cessation. volume. E-cigarette vapours contained a range of chemicals and particu- COI: None; late matter but in lower concentrations compared with cigarette smoke. Grant Support: AUD25.000 the Hospital Research Foundation. Conclusion: This study showed that chronic e-cigarette vapour exposure is not harmless, but results in impairments in lung function. We also showed that the e-cigarette excipient used is important, with the most severe impairments seen in mice exposed to vegetable glycerin-based vapour. Our results suggest that caution should be exercised when advocating e-cigarettes as a safe alternative to tobacco smoking and that further research in this field is warranted. Grant Support: Supported by the WA Department of Health.

TO 045 TSANZ Ann Woolcock Young Investigator Awards Oral Presentations INTERVENTIONS FOR TOBACCO USE PREVENTION IN INDIGENOUS YOUTH: A COCHRANE SYSTEMATIC REVIEW AND META-ANALYSIS TO 046 JAYASINGHE H1,2,3, CARSON K1,2,3, VAN AGTEREN J1,2,PETERSM4, CLIFTON V5, SMITH B1,2,3 1 2 School of Medicine, The University of Adelaide, SA 5000, Clinical Practice BROMODOMAIN INHIBITORS REVERSE THE DISEASE 3 Unit, Basil Hetzel Research Institute, SA 5011, Respiratory Medicine, The FEATURES IN EXPERIMENTAL CHRONIC OBSTRUCTIVE 4 Queen Elizabeth Hospital, SA 5011, Department of Medicine, Concord PULMONARY DISEASE Medical School, NSW, 2006, 5Mater Research, Translational Research Institute, QLD, 4102 JONES B1,HARRISONC1,WATERSD1,DUAK1, STARKEY M1,JARNICKI A1, SMITHERS N2,KNIGHTD1,WARKP1,ADCOCKI3, HANSBRO P1 Aim: Our aim is to evaluate the effectiveness of tobacco prevention inter- 1Centre for Asthma & Respiratory Diseases, The University of Newcastle, < 2 3 ventions for Indigenous youth ( 25 years) and to summarize these ap- NSW, Australia, Epinova DPU, GlaxoSmithKline, Stevenage, UK, The proaches for future prevention programs. Airways Disease Section, National Heart & Lung Institute, Imperial College ’ Methods: The Cochrane Tobacco Addiction Group s specialized register, London, London, UK electronic databases and bibliographies of identified studies were searched up until 2 July 2015. Randomized, non-randomized and controlled clinical Introduction: Chronic obstructive pulmonary disease (COPD) is a pro- trials that had intervention durations of at least 3 months were included. Inter- gressive lung disease characterized by chronic airway inflammation that has ventions could include school-based initiatives, mass media, multicomponent limited treatment options. Emerging evidence suggests that increased histone community level interventions, family-based programs or public policy. Data acetylation is associated with upregulation of pro-inflammatory genes which collection and analysis were performed in line with standard Cochrane guide- drives chronic lung inflammation in patients with COPD. Histone acetylation lines and recommendations. The primary outcome sought was influence on is governed by the opposing effects of histone acetyltransferases (HATs) that smoking behaviour, and the secondary outcome looked at were attitudes, drive acetylation and inhibitory histone deacetylases (HDACs). HAT activity is knowledge and self-efficacy. dependent on a conserved bromodomain, which may be targeted therapeuti- Results: Of 155 citations, six studies met the inclusion criteria. They all cally to reduce aberrant histone acetylation in COPD. involved some form of school-based intervention and follow-up ranged Methods: We assessed the role(s) and therapeutic potential of targeting between 6 months and 5 years. For the primary outcome of tobacco preven- HAT bromodomains in our mouse model of cigarette smoke (CS)-induced ex- tion, five studies showed no evidence of any effect and one favoured control perimental COPD. We treated mice with a highly selective, proprietary arm at final follow-up. Smokeless tobacco use was reported in three studies bromodomain inhibitor for 4 weeks after 8 weeks of CS exposure to induce with no evidence of any effect. Attitudes and self-efficacy were also reported the development of experimental COPD. Treatment was with either continued in one trial showing no difference between groups, whilst a statistically signif- CS exposure or smoking cessation. To assess effects of the inhibitor on a sub- icant benefit was observed for knowledge in one trial. sequent influenza infection, mice with experimental COPD were infected with Conclusion: This review identifies a paucity of data for tobacco prevention 7 PFU influenza and assessed at 7 dpi. Primary mouse and human fibroblasts initiatives tailored to Indigenous youth. The significant result in favour of the and macrophages were also isolated, stimulated with CS extract and cultured control group for the primary outcome of tobacco prevention in one study is with the inhibitor. Mechanistic pathways were assessed using RT-qPCR, disturbing and highlights that assumptions of ‘any intervention is a good ’ ELISA and ChIP-Seq. intervention cannot be made. There is a need for further research into meth- Results: CS-exposed mouse and human lung tissues had aberrant HAT odologically rigorous trials to prevent the uptake of smoking amongst Indige- and HDAC expression and activity which increased histone H4 acetylation. nous youth and to assist in bridging the gap between tobacco-related health Both prophylactic and therapeutic treatment with the bromodomain inhibitor disparities in Indigenous and non-Indigenous populations. abrogated BALF inflammatory cell. Treatment protected against emphy- Grant Support: Nil; COI: None. sema-like alveolar enlargement and restored lung function parameters including airway resistance and TLC. Conclusion: COPD is associated with aberrant histone acetylation. Inhibi- tion of bromodomains restricts progression of experimental COPD, by reducing inflammation, alveolar enlargement and restoring lung function parameters. This inhibition suggests that histone acetylation is a potential driving force that leads to the progression and development of COPD. Inhibition could have the potential therapeutic benefit in human COPD without predispoing to infection. Grant Support: NHMRC. Conflict of interest: None.

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A NOVEL NEUTROPHIL SUPPRESSOR ROLE IN RHINOVIRUS OBESE ASTHMATICS ARE CHARACTERISED BY ALTERED INFECTIONS ADIPOSE TISSUE MACROPHAGE ACTIVATION

TANG F1,2, HANSBRO P3, BURGESS J4,BAINESK3,OLIVERB5 PERIYALIL H1,2,WOODL1,3,KARIHALOOC5,WRIGHTT5,GIBSONP1,2,4 1Woolcock Institute of Medical Research, University of Sydney, NSW, 1Priority Research Centre for Asthma and Respiratory Diseases, 2School of Australia, 2Discipline of Pharmacology, School of Medical Sciences, University Medicine and Public Health, University of Newcastle, NSW, Australia, 3School of Sydney, NSW, Australia, 3Priority Research Centre for Asthma and Respi- of Biomedical Sciences and Pharmacy, University of Newcastle, NSW, ratory Disease, NSW, Australia, 4Department of Pathology and Medical Australia, 4Department of Respiratory Medicine, John Hunter Hospital, Biology, University of Groningen, Groningen, The Netherlands, 5School of NSW. Australia, 5Department of Surgery, John Hunter Hospital, NSW, Medical and Molecular Biosciences, University of Technology Sydney, Australia NSW, Australia Aim: Altered inflammatory profile of obese adipose tissue has now been Introduction/Aim: Rhinovirus (RV) is the major precipitant of asthma exac- well documented. However, it’s unknown how this might contribute to the obe- erbations. Neutrophilic lung inflammation normally occurs during these infec- sity–asthma pathogenesis. The aim of this study was to quantify and immuno- tions. but its role remains unclear. Neutrophilic inflammation is associated phenotype adipose tissue macrophages (ATMs) in subcutaneous and vis- with increased asthma severity and steroid refractory disease. We have found ceral depots of obese asthmatics and controls and to examine the interaction that monocytes but not neutrophils are directly activated by RV and that neu- between adipose tissue, systemic and airway inflammation. trophils suppress monocyte cytokine production. We aimed to determine the Methods:Obese asthmatics and controls were recruited from adults mechanism by which suppressor neutrophils act. scheduled for bariatric surgery. Visceral (VAT) and sub-cutanerous (SAT) ad- Methods: Primary human neutrophils and monocytes were co-cultured +/ ipose tissue sampling was performed during bariatric surgery.The tissue sam- ÀRV16 with either direct contact or separated by transwells (n =5–13). ples were processed to obtain stromal-vascular fraction. Flow cytometry with RV16-stimulated monocytes were exposed to killed neutrophils, neutrophil immuno-fluorescent labelled antibodies was utilized to identify and quantify membrane or soluble neutrophil intracellular components (n =4–6). Co-cul- pro (M1) and anti-inflammatory (M2) macrophage phenotypes. Systemic in- ture of monocytes and neutrophils were cultured with anti-PD1 (n =3)and flammation was measured by estimating CRP. Airway inflammation was anti-TGF-β1(n = 4) antibodies. Monocytes were incubated with TGF-β1 assessed by quantifying inflammatory cells in sputum. – μ Results: (4 andÀ 20 ng/mL) (n = 6), H2O2 (0.0125 nM 100 M) (n = 4) and indometha- In this study, VAT was observed to have a significantly higher cin (10 6M). IL-6 and CXCL8 mRNA and proteins were measured by qPCR number of ATMs, compared to SAT (p = <0.001). A significantly higher per- and ELISA at 24 h (n =4–7). NF-κB p65 expression in monocytes was centage of ATMs, particularly the pro-inflammatory M1 ATMs was observed assessed by western blot (n =4). in VAT of obese asthmatics (p = 0.044), compared to obese controls. Among Results: Neutrophils suppressed 75% of basal IL-6 and CXCL8 release all subjects, the increased percentage of M1 ATMs in VAT was positively as- from monocytes and 50–60% in the presence of RV16. Transwell separation sociated with sputum macrophage count (r = 0.445, p = 0.038). There was a abolished this anti-inflammatory response. Killed neutrophils, neutrophil mem- negative association between M1 : M2 ratio in VAT and FEV1% predicted branes and soluble neutrophil components reduced monocyte IL-6 and (r = À0.490, p = 0.011). In obese asthmatics, CRP was positively associated CXCL8 release in the presence and absence of RV16 (50–90% reduction). with M1 : M2 ratio in VAT (r =0.54, p = 0.049). An increased ratio of M1 to Anti-PD1, anti-TGF-β1 and indomethacin had no effect on the ability of neutro- M2 ATMs was noted in obese asthmatics (p = 0.026) with increased disease phils to suppress monocyte cytokine release basally and with RV16 stimula- severity. tion. TGF-β1 suppressed CXCL8 but not IL-6 in monocytes. Monocytes Conclusions: The increased percentage of M1 ATMs in VAT and its asso- cultured with neutrophil intracellular components had reduced expression of ciation with systemic inflammation and clinical aspects of obese asthmatics NF-κB p65 and IL-6 and CXCL8 mRNA. are suggestive of a predominant macrophage-centric immune pathway in this Conclusions: We propose that neutrophils contact monocytes and release cohort. Further exploration of the mechanistic basis of these associations may an unknown intracellular mediator to act on monocytes. This mediator reduces enable us to have a greater understanding of the pathogenesis of obese expression of NF-κB p65, resulting in reduction of IL-6 and CXCL8 mRNA ex- asthma and to identify specific therapeutic targets. pression and subsequently a reduction in cytokine release. Grant Support: Asthma Australia PhD Scholarship. Grant Support: Nil. Nomination for the Ann Woolcock Young Investigator Award

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SUPERIORITY OF A COURSE OF VARENICLINE TARTRATE KCA3.1 ION CHANNEL-BLOCKADE ATTENUATES PLUS COUNSELLING OVER COUNSELLING ALONE FOR ESTABLISHED PULMONARY FIBROSIS IN A SEGMENTAL SMOKING CESSATION: A 24-MONTH RANDOMISED BLEOMYCIN CHALLENGE MODEL IN SHEEP CONTROLLED TRIAL FOR INPATIENTS ORGAN L1, KOUMOUNDOUROS E2, BACCI B1,SAMUELC3, KIMPTON CARSON K1,2, BRINN M2,PETERSM3,FITRIDGER4,KOBLARS5,6, W1,SNIBSONK1 JANNES J5,6,SINGHK7,VEALEA1, GOLDSWORTHY S8,LITTJ9, 1Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, ESTERMAN A10, SMITH B1,2 2Department of Electrical and Electronic Engineering,The University of 1Respiratory Medicine, The Queen Elizabeth Hospital, South Australia, Melbourne, 3Department of Pharmacology, Monash University Australia, 2School of Medicine, The University of Adelaide, Australia, 3Tho- 4 racic Medicine, Concord Clinical School, New South Wales, Australia, Divi- Introduction/Aim: The KCa3.1 ion channel has been shown to be involved sion of Surgery, The Queen Elizabeth Hospital South Australia, Australia, in the lethal fibrotic lung disease, idiopathic pulmonary fibrosis. Inhibition of the 5 Stroke Research Program, The University of Adelaide, South Australia, KCa3.1 ion channel-dependent processes in vitro is able to prevent pro-fi- 6 Australia, Stroke Unit, The Queen Elizabeth Hospital, South Australia, brotic activity.The current study aims to investigate whether inhibition of 7 Australia, Department of Cardiology, University of Ottawa Heart Institute, On- KCa3.1 in vivo can attenuate established fibrosis in a sheep model of pulmo- 8 tario, Canada, Pharmacy, The Queen Elizabeth Hospital, South Australia, nary fibrosis. 9 Australia, Discipline of General Practice, Flinders University, South Australia, Method: Two separate lung segments in 20 sheep received two fortnightly 10 Australia, School of Nursing and Midwifery, The University of South Austra- instillations of either bleomycin (BLM 3U), or saline (control). Two weeks after lia, South Australia, Australia the final BLM dose, sheep were randomly assigned to two treatment groups (10 per group) and were given a 7-week regimen of twice daily oral administra- Introduction/aim: Current evidence suggests superior efficacy of tions of either 30 mg/kg Senicapoc (ICA-17073), a selective inhibitor of varenicline tartrate for smoking cessation over that of other tobacco cessation KCa3.1, or vehicle alone (0.5% methylcellulose). Lung function was mea- therapies; however, all of these publications are presented in the outpatient sured at 2, 4 and 7 weeks post BLM. Histopathology scoring and collagen setting and are sponsored by Pfizer, the manufacturer of the medication. content were measured to assess the degree of fibrosis. Several recent publications have also highlighted concerns around safety Results: In vehicle-treated sheep, BLM-treated lobes had prominent fibro- and tolerability, particularly amongst smokers with co-morbidities. Given these sis compared to saline controls (pathology scores 12.82 ± 1.7 vs. 1.4 ± 0.7, apprehensions, we aimed to evaluate the efficacy, safety and tolerability of n =10, p < 0.0001); hydroxyproline content (4.7 ± 0.5 vs. 3.4 ± 0.3 %, varenicline tartrate plus Quitline-counselling compared to Quitline-counselling n =10,p = 0.004). By contrast, sheep treated with Senicapoc has reduced pa- aloneintheinpatient setting. thology and collagen in BLM-treated lobes when compared to BLM-vehicle Methods: All adult patients (20–75 years) admitted with an acute smoking- lobes (Pathology: BLM-senicapoc 4.6 ± 1.6 vs. BLM-vehicle 12.82 ± 1.7, related illness to one of three South Australian hospitals were screened for n =10, p = 0.001; hydroxproline: 3.8 ± 0.54 vs. 5.7 ± 0.64%, n =10, eligibility. Subjects were randomized to receive either 12-weeks of varenicline p = 0.08). BLM-vehicle lobes were significantly less compliant compared to tartrate (titrated from 0.5 mg daily to 1 mg twice-daily) plus Quitline-counselling corresponding saline lobes (À56.5 ± 7.3 vs. 2.34 ± 21% change baseline, (VT + C), (n = 196) or Quitline-counselling alone (n =196). n =10, p = 0.009). Loss BLM-induced lung function was prevented in Results: A total of 1959 potential subjects were screened for eligibility Senicapoc treated sheep (BLM-veh vs. BLM-sen: À56.5 ± 7.3 vs. 3.3 between August 2008 and December 2011. For the primary analysis popula- ± 29.7% change baseline, n =10,p =0.05). tion (intention-to-treat), the proportion of subjects who remained continuously Conclusion: These results show that treatment with Senicapoc was able abstinent at 12 months were significantly greater in the VT + C arm (31.1%, to improve both structural and functional features of established fibrosis, n = 61) compared to counselling alone (21.4%, n = 42; RR 1.45, 95%CI 1.03 supporting that the KCa3.1-channel may be a viable therapeutic target for hu- to 2.03, p = 0.03). Significance was maintained at 24 months follow-up (VT man pulmonary fibrotic disease. +C,29%n = 56 compared to counselling alone, 18% n =36;p =0.02).The Key words: fibrosis, large animal model, therapy most common self-reported adverse event during the 12-week treatment Nomination for Young Investigator Award: Yes phase was nausea with 16.3% in the VT + C group compared with 1.5% in Grant Support: Internal the counselling alone group. Thirteen deaths occurred during the treatment period (n = 6 for VT + C and n = 7 for counselling alone). All of these subjects had known or developed underlying co-morbidities. Conclusion: This is the first study to examine the efficacy and safety of varenicline tartrate over 24 months within any setting. VT + C appears to be an effective, safe and well-tolerated opportunistic treatment for inpatient smokers with tobacco-related chronic disease. Grant Support: Nil; COI: None.

TO 051 Evidence-Based Medicine and Practice Oral Presentations NLRP3 INFLAMMASOME-MEDIATED, IL-1β-DEPENDENT INFLAMMATORY RESPONSES DRIVE SEVERE, STEROID- INSENSITIVE ASTHMA TO 052 KIM R1, PINKERTON J1, ESSILFIE A1, ROBERTSON A2, BAINES K1, MAYALL J1, STARKEY M1,WARKP1,GIBSONP1,O’NEILL L3,COOPER M2,HORVATJ1, HANSBRO P1 1Priority Research Centre for Asthma and Respiratory Diseases, Hunter Med- EXHALED NITRIC OXIDE (FENO) LEVELS TO GUIDE ical Research Institute and The University of Newcastle, Newcastle, New TREATMENT FOR ADULTS WITH ASTHMA: A COCHRANE South Wales, Australia, 2Division of Chemistry and Structural Biology, Institute SYSTEMATIC REVIEW for Molecular Bioscience, The University of Queensland, Brisbane, Queens- 3 land 4072, Australia, School of Biochemistry and Immunology, Trinity PETSKY H1,KEWK2,TURNERC3, KYNASTON J4,CHANGA5 Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland. 1Queensland University of Technology, 2Population Health Research Insti- tute, University of London, 3School of Nursing, Midwifery and Social Work, 4 5 Introduction/Aim: Excessive NLRP3-inflammasome and concomitant IL- The University of Queensland, Lady Cilento Children’sHospital, Child 1β responses are implicated in many inflammatory diseases. However, the di- Health Division, Menzies School of Health Research rect contributions to pathogenesis, mechanisms involved and potential for therapeutic targeting remain poorly understood. In the lung, NLRP3 Introduction/Aim: Obtaining FeNO levels routinely in clinical practice adds inflammasomes are associated with emphysema, infections and severe, to the burden of asthma care and resource utilization. On the other hand, rou- steroid-insensitive (SSI) asthma. SSI asthma is the major unmet clinical need tine use of FeNO levels to guide therapy may improve asthma control and re- in asthma management. It is underpinned by exaggerated innate and TH1/ duce exacerbations and hospitalizations related to asthma. The objective of TH17 immunity, neutrophilic inflammation and bacterial infections. this Cochrane systematic review was to evaluate the efficacy of tailoring Methods: We developed novel mouse models of Chlamydia,andHae- asthma therapy based on FeNO levels, in comparison with not using FeNO mophilus, respiratory infection and ovalbumin-induced, severe, neutrophilic, (i.e. management based on clinical symptoms and/or asthma guidelines), for steroid-insensitive allergic airways disease (SSIAAD) in BALB/c mice. These asthma-related outcomes in adults. In our original review, we found that use models share the hallmark features of human disease, including elevated of FeNO strategy did not confer any benefit. NLRP3 inflammasome and concomitant IL-1β responses. We also examined Methods: The Cochrane Register of Controlled Trials (CENTRAL), the the relationships between NLRP3 and caspase-(CASP)1 levels and airway Cochrane Airways Collaborative Review Group Specialised Trials Register, neutrophil numbers and disease severity in a population of human asthmatics. MEDLINE, EMBASE and CINAHL databases were searched by the The roles and potential for targeting of infection-induced NLRP3- Cochrane Airways Group. The latest search was performed in January inflammasome, caspase-(CASP)1 and IL-1β responses in the lung in SSIAAD 2015. All randomized controlled trials comparing adjustment of asthma medi- were examined using therapeutic treatments with a potent, highly selective cations based on FeNO levels with clinical symptoms were eligible to be in- NLRP3 inhibitor, MCC950, the specific CASP1 inhibitor, Ac-YVAD-cho and cluded. Results of searches were reviewed against pre-determined criteria neutralizing anti-IL-1β antibody, α-IL-1β, respectively. for inclusion. Results: We show that Chlamydia and Haemophilus respiratory infections Results: Seven studies were included. Of the 1700 participants random- increase NLRP3, CASP1, IL-1β and TH1/TH17 responses, which drive ste- ized, 1546 completed the trial. Six studies reported significant reduction in roid-insensitive neutrophilic inflammation and airways hyper-responsiveness asthma exacerbations when treatment was based on FeNO levels in compar- in novel models of experimental SSI asthma. Neutrophilic airway inflammation ison to clinical symptoms; OR 0.60 (95% CI 0.43 to 0.84). Secondary out- and severity of human SSI asthma correlated with IL-1β and NLRP3 expres- comes did not show significant difference between the groups. sion. Treatment with Ac-YVAD-cho, α-IL-1β and MCC950 completely attenu- Conclusion: With the availability of studies since our last review, the meta- ated IL-1β responses and the important steroid-insensitive features of analysis shows that in adults with asthma, tailoring asthma medications based disease. on FeNO levels (compared with primarily on clinical symptoms) decreases the Conclusion: We have identified a previously unrecognized pathogenic frequency of asthma exacerbations but has not been shown to impact on day- role for an NLRP3/CASP1/IL-1β axis in severe, neutrophilic, steroid-insensi- to-day clinical symptoms or ICS dose. tive asthma. NLRP3-inflammasome responses may drive SSI asthma and Grant Support: HLP is supported by post-doctoral fellowship through be therapeutically targeted in this and other NLRP3-mediated diseases. NHMRC CRE and Asthma Australia Early Career Fellowship. A. C. is sup- Grant Support: NHMRC and HMRI. ported by NHMRC fellowship. Conflict of interest: None.

TO 053 TO 054

OXYGEN THERAPY IN THE PRE-HOSPITAL SETTING FOR THE EFFECTIVENESS OF SHORT-ACTING ACUTE EXACERBATIONS OF COPD: A COCHRANE BRONCHODILATORS FOR THE MANAGEMENT OF ACUTE SYSTEMATIC REVIEW EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN THE INPATIENT OR HOSPITAL SETTING: A KOPSAFTIS Z1,2,3,CARSONK1,2,3,AUSTINM4,WOOD-BAKERR5, SYSTEMATIC REVIEW SMITH B1,2,3 1School of Medicine, The University of Adelaide, South Australia, Australia, SULAIMAN N1, KOPSAFTIS Z1,2,3, CARSON K1,2,3,PHILLIPSP4,5, 2Respiratory Medicine, The Queen Elizabeth Hospital, South Australia, Aus- SMITH B1,2,3 tralia, 3Clinical Practice Unit, The Basil Hetzel Institute for Translational Health 1Respiratory Medicine, The Queen Elizabeth Hospital, South Australia, Research, South Australia, Australia, 4Discipline of Medicine, University of Australia, 2School of Medicine, The University of Adelaide, South Australia, Tasmania, Tasmania, Australia, 5Primary Health Care: Nelson Group, Men- Australia, 3Clinical Practice Unit, The Basil Hetzel Institute for Translational zies Institute for Medical Research, Tasmania, Australia Health Research, South Australia, Australia, 4Department of Medicine, Flinders University, South Australia, Australia, 5SA Health, Government of Aim: Our aim is to determine the effect of different inspired oxygen concen- South Australia, South Australia, Australia trations in the pre-hospital setting on outcomes for people with acute exacer- bationsofCOPD(AECOPD). Aim: Our aim is to evaluate the effectiveness of short-acting bronchodila- Methods: Two independent researchers screened the Cochrane Airways tors (SABD) for inpatient management of acute exacerbation of chronic ob- Group specialized register, online clinical trial registries and bibliographies of structive pulmonary disease (AECOPD) to underpin future guidelines. publications to identify studies for inclusion. Randomized controlled trials com- Methods: A search of Medline, Embase and online clinical trial registries paring oxygen therapy at different concentrations or oxygen therapy exam- (to June 2015) were screened by two independent researchers. Included ined against a control (placebo, low-concentration or usual care) were studies had a quantitative design and investigated patients with AECOPD ad- included. Data extraction occurred using a standardized template by two inde- mitted to hospital. Interventions could include short-acting β2 agonists, pendent authors. Analysis was performed with RevMan v5.3 in line with stan- ipratropium or a combination of these. Data were examined using narrative dard Cochrane guidelines and recommendations. synthesis and where possible meta-analysis via standardized mean differ- Results: From 870 citations, four studies met all of the inclusion/exclusion ence and 95% confidence intervals (CI). Data extraction occurred using a criteria. All studies investigated oxygen therapy for AECOPD in the pre-hospi- standardized template by two independent authors and analysis with REVIEW tal (emergency/paramedic) setting. One of the studies was identified as ongo- MANAGER software version 5.3 using standard Cochrane methodology. ing, and two were terminated prior to completion leaving only one completed Results: From 557 citations, a total of 11 studies met the inclusion/exclu- study for inclusion. A comparison of titrated nasal oxygen for saturation of sion criteria. Included articles were methodologically diverse, and the risk of 88–92% was compared to nebulized high-flow oxygen (6–8L/min). Of the bias was assessed as being poor to average. The primary outcome, treatment 405 patients identified by paramedics, 214 had confirmed diagnosis of COPD. failure, was not able to be pooled in an analysis as only one study examined For these patients, significantly higher mortality was noted with high-flow oxy- this. Meta-analysis of three studies for FEV1 (0.00 [95%CI; À0.49, 0.50]) gen therapy (9%) versus titrated oxygen therapy (2%) (relative risk 0.22, 95% and FVC (À0.11 [95%CI; À0.92, 0.71]) revealed no evidence of any effect. CI 0.05–0.91; P = 0.04). Risk of bias assessment revealed overall good meth- Narrative synthesis demonstrated no significant differences with clinical out- odology, with a high risk of bias for blinding of participants and outcome comes regardless of dose, delivery method and type of SABD used; however, assessors. larger doses of some medications were associated with more adverse events. Conclusion: There is a paucity of evidence to indicate whether different ox- No included studies reported optimal duration of short-acting bronchodilator ygen therapies in the pre-hospital setting have an effect on outcomes for peo- administration. ple following an AECOPD. However, there is some indication that titrated Conclusions: Minimum dosages with any delivery method were just as ef- nasal oxygen therapy results in lower mortality compared to nebulized high- fective as higher doses in terms of efficacy of SABD. However, higher doses flow. Methodologically, rigorous trials are required to address this evidence were associated with an increase in adverse events, suggesting that current gap for oxygen use in the pre-hospital setting, particularly given its routine practices assuming a higher dose to be more effective may be erroneous. use in standard clinical practice despite the lack of empirical evidence to sup- The lack of methodologically rigorous and up-to-date studies limits the ability port its use. to draw reliable conclusions to underpin recommendations for clinical practice. Grant Support: Nil; Grant Support: Nil; COI: None. COI: None.

TO 056 Lung Cancer 1 Oral Presentations

THE ROLE OF STAT3 SERINE PHOSPHORYLATION IN THE KRAS-INDUCED LUNG CANCER DEVELOPMENT TO 055 ALHAYYANI S, RUWANPURA S, JENKINS B Hudson Institute of Medical Research

GENETIC PROFILING OF MALIGNANT MESOTHELIOMA IN Introduction: Lung adenocarcinoma (LAC) is the number one cancer killer PLEURAL EFFUSIONS SHOWS HIGH VARIABILITY worldwide. LAC is strongly associated with chronic lung inflammation trig- gered by cigarette smoking, and one of the most established disease-associ- SNEDDON S1, BROWN S2,3,HOLTR2,ROBINSONB1, CREANEY J1 ated consequences of the genotoxic effects of cigarette-derived carcinogens 1National Centre for Asbestos Related Diseases, School of Medicine and is activating mutations in the Kras. The STAT3 oncoprotein is persistently ac- Pharmacology, University of Western Australia, WA, Australia, 2Michael Smith tivated in LAC. Our lab has recently discovered that IL-6 via the simultaneous Genome Sciences Centre, BC Cancer Agency, British Columbia, Canada, activation of STAT3 and Kras lead to LAC. Despite above discoveries, the 3Genome Science + Technology Graduate Program, University of British complex mechanistic basis by which STAT3 promotes LAC remains ill- Columbia, British Columbia, Canada defined. More recently, a mitochondrial pool of STAT3 that promotes tumourigenesis by regulating metabolic processes independent of its tran- Introduction/Aim: High-throughput sequencing of malignant mesotheli- scription factor activity has been discovered, thus changing the landscape by oma (MM) tumours allows for the identification of genetic variation and tran- which STAT3 acts as an oncogene. This relatively new role for the mitochondrial activity of STAT3 is dependent on its phosphorylation at the serine (S) scriptome dynamics and furthers our understanding of MM tumour biology. SA/SA Expression of immune-related genes in tumour infiltrate has been shown to 727 site, which has been shown using Stat3 knock-in mice carrying a correlate with survival in other cancers. Pleural effusion offers an opportunity STAT3 mutant incapable of being phosphorylated on S727. We therefore to investigate the immune infiltrate at a site proximal to the tumour. Under- hypothesize that STAT3 serine phosphorylation is a downstream key event standing the genetic and immune components of MM presents the opportunity in the molecular pathogenesis of LAC. We aim to demonstrate that STAT3 to classify the disease in terms of survival and treatability in a personalized serine phosphorylation promotes molecular/cellular responses in the Kras- manner beyond current measures. induced LAC. Methods: At 6 weeks of age, Stat3SA/SA mice genetically combined with Methods: Short-term cultures were established from the pleural effusion of G12D SA/SA 30 MM patients. Whole exome sequencing was performed on cell lines and Kras mice (Kras : Stat3 ) were inhaled with a single dose of Cre matched normal blood samples. Transcriptome sequencing was performed recombinase to activate the Ras G12D gene. Lungs were collected after 6 weeks of inhalation on the complete cellular component present in the effusion. Sequencing G12D SA/SA was performed on the Ion Torrent Proton system. Somatic variants (SNVs) Results: LAC was reduced by 20% in Kras :Stat3 mice compared to parental KrasG12D mice. We also report that compared to control KrasG12D were identified using probabilistic and heuristic methods. Copy number varia- G12D SA/SA tion (CNV) and mutational signatures were identified using GISTIC2.0 and mice, Kras :Stat3 mice showed reduced lung cellular proliferation, SomaticSignatures, respectively. Expression of CD8A, GZMA and PRF1 reduced inflammation, while apoptosis remained unchanged. was used as a surrogate measure of cytotoxic T cell activity. Patient demo- Conclusions: Our genetic approaches have demonstrated the importance graphic, treatment response, survival and asbestos-exposure data were of STAT3 serine phosphorylation in the Kras-induced lung carcinogenesis collected. in vivo. This mitochondrial form of STAT3 can be eventually targeted thera- Results: Significant copy number loss was observed frequently across all peutically to block tumour growth whilst sparing the required nuclear activities samples. Tumours harboured a median of 397 SNVs (range 93–901). Muta- of STAT3 in normal tissues. tions and loss in known tumour suppressor genes such as BAP1, CDKN2A and TP53 were identified. Initial analysis showed no association between CD8A expression and survival. The mutational spectrum was dominated by C > T transitions and TCA > TAA mutations, possibly indicative of an asbestos-related signature. Conclusion: MM is a complex tumour consisting of frequent genetic loss with a wide range of variation between patients. Pleural effusion can provide an informative window to the MM tumour microenvironment which is rich in immune infiltrate that can be sequenced and linked to clinical data. Identification of the biological significance of these findings will provide an avenue for future translation into the clinic. Grant Support: The Divett Foundation, HIA Charitable Foundation, Insur- ance Commission of Western Australia, UWA Convocation, UWA Graduate Research School. Nomination: Ann Woolcock Young Investigator Award Conflict of Interest: No

TO 057 TO 058

STRATEGIES FOR IMPROVING IMMUNOTHERAPY FOR LUNG THE ROLE OF CHEMOKINE (C-C MOTIF) LIGAND 2 (CCL2) IN TUMOURS—IDENTIFYING TUMOUR ANTIGENS USING GENE MESOTHELIOMA-INDUCED MALIGNANT PLEURAL SEQUENCING. EFFUSION FORMATION

Robinson B LANSLEY S1,CHEAHH1,2,RINALDIC2,3,CREANEYJ2,3, LEE Y1,2,4 University of Western Australia 1Institute for Respiratory Health, 2School of Medicine and Pharmacology, Uni- versity of Western Australia, Australia, 3National Centre for Asbestos Related 4 Introduction/Aim: Lung tumour immunotherapy is now proving to be very Diseases, University of Western Australia, Australia, Department of Respira- effective, with about 20% of patients responding extremely well to ‘checkpoint tory Medicine, Sir Charles Gairdner Hospital, Perth, Australia blockade’ agents such as antiPD1/PDL1. A key to improving responses in the remaining 80% of patients will be the identification of mutation-specific im- Introduction: More than 90% of malignant pleural mesothelioma (MPM) mune responses and their augmentation by therapies, such as vaccination patients present with pleural effusion. Current methods of managing effusions or immunogenic chemotherapy. are limited. Therefore, identifying mechanisms of malignant effusion formation Methods: In this study, we successfully identified mutation-specific im- may provide novel therapeutic options. mune responses by (a) identifying mutations using RNA and exome sequenc- Aim: Determine the role of CCL2 in contributing to MPM effusion ing of several murine pulmonary tumours which are homologs of their human development. counterpart, (b) predicting which of those mutations could be immunogenic by Methods: Expression of CCL2 mRNA and protein in human (n =11)and using the NetMHCpan 2.8 algorithm to predict the binding affinity of mutated mouse (n = 9) mesothelioma cell lines was measured by RT-PCR and CCL2 peptides and (c) determining which of these mutations might trigger immune protein expression and distribution in human and mouse cells examined by responses by testing the immunoreactivity of host T cells to these mutation- immunocytochemistry. CCL2 levels were quantified by ELISA in pleural fluid carrying peptides. supernatants from 197 patients. Pleural fluid samples (n = 298) collected lon- Results: A strong immune response was demonstrated to Uqcrc2, a com- gitudinally from MPM patients were also assessed for changes in CCL2 ponent of the respiratory pathway. Importantly, this response was greater in levels. In vivo effects of CCL2 inhibition on MPM-induced pleural effusion were the draining lymph node versus spleen. This suggests that the dLN might gen- examined using a CCR2 antagonist delivered intraperitoneally for four con- erally be a better location to look for neo-antigenic reactivities, an observation secutive days. that has significant implications for EBUS sampling in lung cancer patients. Results: All mouse and human mesothelioma cell lines expressed CCL2 We then determined if the response to mutated antigens could be altered by mRNA and protein. CCL2 protein was distributed within the nucleus and cyto- therapy. Removing suppressive ‘regulatory T cells’ augmented and broad- plasm of mesothelioma cells. CCL2 levels were significantly higher in MPM ened the immune response to neo-antigens, but checkpoint blockade and im- pleural effusions (n = 78) than in non-MPM pleural fluids (n =119;frommeta- munogenic chemotherapy only boosted the existing Uqcrc2 response. static pleural carcinomas/benign causes): median 1140 vs 450 pg/mL, re- Conclusions: This work confirms that the approach taken, cancer gene spectively, p = 0.02. Longitudinal measurements of pleural fluid CCL2 levels sequencing combined with peptide prediction and T-cell testing, before and af- in 35 patients showed a significant increase in CCL2 expression (0.37 ter therapy can identify patterns of response to mutated tumour antigens, pro- ± 0.13 pg/mL/100 days, p = 0.005) as tumour progressed. Extensive pleural viding a strong platform for translation into clinical trials in patients with lung mesothelioma tumour and large pleural effusions were induced in CBA mice cancer and mesothelioma. This work has formed the basis of our current clin- (n = 10) by intrapleural injection of mesothelioma (AC29) cells. CCR2 antago- ical studies in this field. nist treatment significantly reduced effusion volumes; controls: 843 (median, Grant support: NHMRC, ICWA, WA govt, Divett Fndn, HIAA. IQR 583–1234) μL vs treatment group 270 (146–835) μL, p =0.038. Conclusions: CCL2 is significantly over-expressed in MPM effusions. Inhi- bition of CCL2 activity potently reduced the formation of MPM effusion. CCL2 represents a potential therapeutic target to control MPM malignant effusions. Grant Support: This project is supported by the NSW Workers’ compensa- tion Dust Disease Board, NSW.

TO 059 TO 060

INTERLEUKIN-6 TRANS-SIGNALLING AS A NOVEL NEXT GENERATION SEQUENCING ON ENDOBRONCHIAL THERAPEUTIC TARGET AND A BIOMARKER FOR LUNG ULTRASOUND TRANSBRONCHIAL NEEDLE ASPIRATE CANCER LYMPH NODE SPECIMENS IN LUNG CANCER SHOWS A HIGH INCIDENCE OF MUTATIONS AND CONSISTENCY WITH RUWANPURA S1,BROOKSG1,MCLEODL1, ALHAYYANI S1,MILLERA1, SINGLE GENE TESTING FERLIN W2,ROSE-JOHNS3, JENKINS B1 1Hudson Institute, 2NovImmune SA, Geneva, Switzerland, 3Institute of FIELDING D1, BASHIRZADEH F1,SINGHM2,NANDAKUMARL2,MCCART Biochemistry, Christian-Albrechts-University, Olshausenstrasse 40, D-24098 REED A3,BLACKD3,DALLEYA3, PEARSON J5,NONESK5,WADDELLN5, Kiel, Germany SIMPSON P3,4, LAKHANI S2,3,4 1Royal Brisbane and Womens Hospital, 2Pathology Queensland, Queens- 3 Introduction/Aim: Oncogenic mutations in KRAS are a common feature of land, Australia, The University of Queensland Centre for Clinical Research, 4 human lung adenocarcinoma (LAC), although the identity of signalling net- Queensland, Australia, The University of Queensland School of Medicine, 5 works which engage KRAS to promote LAC remains ill-defined. In that regard, Queensland, Australia, QIMR Berghofer Medical Research Institute, the potent immunomodulatory cytokine interleukin-6 (IL-6) is up-regulated in Queensland, Australia lung cancer and therefore represents an exciting prospect for therapeutic targeting. Here, we aim to identify whether IL-6 signalling promotes KRAS-in- Introduction/Aim: Next generation sequencing (NGS) has been success- duced lung cancer. fully applied on diagnostic lung cancer samples; however, there are no reports Methods: We have coupled the Cre recombinase-inducible KrasG12D/+ of lymph node material sampled at endobronchial ultrasound transbronchial LAC mouse model with gp130F/F mice, the latter harbouring a knock-in muta- needle aspiration (EBUS TBNA). tion in gp130 which abrogates suppressor of cytokine signalling (SOCS)3-me- Methods: A prospective study was performed on patients having EBUS diated down-modulation of IL-6 cytokine family/STAT3 signalling. TBNA. Samples were taken for conventional histology on formalin fixed paraf- Results: Lung tumourigenesis was accelerated in gp130F/F:KrasG12D mice fin embedded (FFPE) blocks. DNA was extracted from these blocks and sub- compared to parental KrasG12D mice and was characterized by a hyper-prolif- jected to the Truseq Amplicon Cancer Panel (Illumina, San Diego, CA) NGS of erative phenotype comprising marked atypical adenomatous hyperplasia a pre-defined set of 48 cancer-related genes in a cohort of 67 malignant nodes (AAH) and adenocarcinoma in situ (AIS), often invasive, throughout the lung. on the MiSeq platform. Mutations were identified using qSNP, and potential Among IL-6 family cytokines, only the expression of IL-6 was upregulated in germline variants were filtered if they contained a variant allele frequency in gp130F/F:KrasG12D mouse lungs, and the severity of LAC in gp130F/F: the general population of <1%. Data on ALK and EGFR mutation testing by KrasG12D mice was suppressed upon either homozygous or heterozygous ab- standard lab PCR were available on all patients. lation of Il6 or Stat3, respectively, each of which normalizes pulmonary STAT3 Results: Histology was primary lung cancer in 64 patients (adenocarci- activity. Moreover, protein levels of the soluble IL-6 receptor (sIL-6R), the key noma 41, squamous cell 10, small cell 10 and large cell carcinoma 3) and met- driver of IL-6 trans-signalling, were elevated in the lungs of gp130F/F:KrasG12D astatic malignancy in three cases. DNA yield was sufficient to allow NGS in 44 mice, and a specific role for IL-6 trans-signalling in driving the exacerbated cases. Thirty-two of the samples contained at least one non-silent likely so- LAC phenotype in gp130F/F:KrasG12D mice was demonstrated by amelioration matic mutation (range 1–6). Mutations were detected in 25 of the investigated of LAC upon either the transgenic expression of the specific IL-6 trans-signal- cancer-related genes. The most commonly mutated gene was TP53 (n =15 ling inhibitor, sgp130Fc, or administration of mice with monoclonal antibodies patients) with two patients containing a nonsense mutation. Other well-de- (mAbs) which target IL-6 trans-signalling. Notably, the expression of IL-6 and scribed alterations included activating codon 12 (n = 7) and codon 61 (n =1) sIL-6R was also significantly increased in human LAC patient biopsies and mutations in KRAS, HRAS (n =2),PIK3CA (n =2),SMAD4 (n =2)andPTEN serum. (n = 3). An EGFR mutation (L858R) was present in only one case, and this Conclusion: Collectively, our observations provide the rationale for the was the only case which also had a corresponding EGFR mutation in exon clinical evaluation of IL-6 trans-signalling as a new target for the treatment of 21 by PCR: coding sequence c.2573T > G; amino acid p.Leu858Arg. LAC. Conclusions: NGS is feasible on EBUS TBNA samples and shows a high incidence of mutations, including well-known ‘druggable targets’.EGFRmuta- tion testing exactly correlated with lab PCR. Grant Support: Pathology Queensland Study Grant. Declaration of Interest Statement: No competing interests.

TO 062 Paediatric 2 Oral Presentations

IMPACTS OF MATERNAL VITAMIN D DEFICIENCY ON LUNG TO 061 DEVELOPMENT

CHEN L1,WILSONR2,BENNETTE1,ZOSKYG1 1School of Medicine, Faculty of Health, University of Tasmania, Hobart, ≥ 2 MATERNAL SERUM VITAMIN D LEVELS 75 NMOL/L DURING Tasmania, Australia, Central Science Laboratory, University of Tasmania, PREGNANCY ARE ASSOCIATED WITH FEWER ADVERSE Hobart, Tasmania, Australia RESPIRATORY OUTCOMES IN INFANTS AT 12 MONTHS OF AGE Introduction: A plethora of studies have shown cross-sectional associa-

1 1 1 1,3 2 tions between vitamin D deficiency and postnatal lung function; however, JENSEN M ,MURPHYV,MATTESJ,GIBSONP , CARMARGO JR C the mechanisms underlying these associations remain uncertain. We have 1Centre for Asthma and Respiratory Diseases, University of Newcastle, 2 3 previously shown that vitamin D deficiency has a detrimental impact on lung Emergency Medicine Network, Massachusetts General Hospital, Depart- development using a mouse model. In this study, we aimed to identify the po- ment of Respiratory and Sleep Medicine, John Hunter Hospital tential mechanisms linking vitamin D with lung development. Methods: Vitamin D deficient and replete female BALB/c mice were mated Introduction/Aim: Maternal nutritional status has been linked to infant with replete male mice. Female offspring were euthanized at key developmen- health. We hypothesized that higher vitamin D status in women with asthma tal time-points embryonic day (E)14.5, E17.5 or postnatal day (P)7, and lung during pregnancy were associated with fewer adverse respiratory outcomes tissue was collected. Lung protein extracts were digested with trypsin, in infants. analysed by LTQ-Orbitrap tandem mass spectrometry. Label-free quantitation Methods: In pregnant women with asthma recruited from the John Hunter was used to identify the differentially expressed proteins. The expressions of Hospital (latitude 32.93°S), serum total 25-hydroxy-vitamin D (25(OH)D) was selected proteins were confirmed by ELISA. Lung structure was assessed measured at 20 and 36 weeks gestation, using enzyme-linked immunosor- by stereology. bent assay. Infant respiratory outcomes during the first 12 months of life were Results: At E14.5 and E17.5, no differences in protein expression were de- 1 collected using a validated parent-report questionnaire. Mother–infant pairs tected between vitamin D deficient and replete mice, whereas 52 differentially were grouped according to maternal 25(OH)D during pregnancy: 25(OH)D expressed proteins were identified in P7 lungs (FDR adjusted p value < 0.05). ≥75 nmol/L (at one or both time points during gestation), versus 25(OH)D The expression of pulmonary surfactant-associated protein B was reduced in <75 nmol/L (at both time points). P7 lungs of vitamin D deficient mice (p < 0.05), and the production of collagen 1 Strippoli MP et al., Arch Dis Child, 2007, 92, 861–865. type 1 alpha 1 was higher in lungs of vitamin D deficient mice compared to vi- Results: Of 69 mother-infant pairs, 52 had available data; 31 (60%) tamin D replete mice (p < 0.05). There was no difference in lung volume, pa- mothers had 25(OH)D <75 nmol/L at both gestational time points, and 21 renchymal volume, volume of the airspaces or surface area of the airspaces (40%) had 25(OH)D ≥75 nmol/L. Of these 21 mothers, eight (38%) maintained between the lungs of vitamin D deficient and replete mice for all three time- 25(OH)D ≥75 nmol/L at both time points, while the remainder had 25(OH)D points. ≥75 nmol/L at either the first (n = 4 [19%]) or second (n = 9 [43%]) gestational Conclusions: The lack of difference in protein expression in the early de- time point. velopmental time-points suggests that vitamin D deficiency induced alter- Serum 25(OH)D ≥75 nmol/L during pregnancy was associated with a signifi- ations in lung structure and function occur during alveolarization and are cantly lower proportion of infants with ‘wheeze ever’ at 12 months of age, com- driven by reduced surfactant synthesis and increased collagen production. pared with maternal 25(OH)D <75 nmol/L (n =9 [43%]vs. n =22[71%], These data provided a plausible mechanism linking maternal vitamin D defi- p = 0.04). A consistent trend was present for multiple respiratory outcomes ciency with altered postnatal lung function. (Table 1) although none were statistically significant. Grant Support: National Health and Medical Research Council Project Likewise, the proportion of infant acute-care presentations (n = 3 [13%] vs. Grant. n =14 [45%], p = 0.02) and oral corticosteroid use (n = 1 [4%] vs. n =8 [26%], p = 0.03) due to ‘asthma/wheezing’, were significantly lower in the maternal group with 25(OH)D ≥75 nmol/L, versus <75 nmol/L, during gestation. Conclusions: Maternal vitamin D status during pregnancy may influence infant respiratory outcomes and health care usage in the first 12 months of life. This requires further investigation in a larger cohort and eventually in randomized trials. Grant Support: NHMRC, Hunter Medical Research Institute. Declaration of interest: None to declare.

Infant respiratory Maternal 25(OH)D during pregnancy outcome during ﬁrst p- 12 months of life ≥75 nmol/L <75 nmol/L value

≥4Wheezingattacks 3[27%] 8[40%] 0.48 Bronchiolitis ever 5 [24%] 13 [43%] 0.15 Croup ever 0 [0%] 4 [13%] 0.14 ≥4 Colds 7 [33%] 17 [55%] 0.13

TO 063 TO 064

HIGH-FLOW OXYGEN COMPARED TO STANDARD NASAL EXHALED BREATH CONDENSATE: MEASURING CANNULA OXYGEN DOES NOT REDUCE THE MEDIAN TIME INFLAMMATION AND OXIDATIVE STRESS IN PRETERM ON OXYGEN FOR INFANTS WITH MODERATE INFANTS BRONCHIOLITIS URS R1,2,SIMPSONS1,CLARKEM3,PILLOWJ2,HALLG1 KEPREOTES E1, 3,WHITEHEADB1,3, LEE M2,3,COLLISONA3,4,GOD- 1Telethon Kids Institute, 2School of Anatomy, Physiology and Human Biology, DARD B1,3,CHEESEL1,HILTONJ1,3, GULLIVER T1,3,RODDICKL1,3, University of Western Australia, 3UWA Centre for Metabolomics ANSCOMBE M2,3,ZHANGM2,3,ASKIEC1, JENKINSON L1,OLDMEADOW 4 2,3,4 3,4 1 1,3,4 C ,ATTIAJ ,REEVESP ,LEHRLEL,MATTESJ Introduction/Aim: Preterm birth interrupts lung development, often leading 1 2 3 John Hunter Children’sHospital, John Hunter Hospital, University of New- to diagnosis of bronchopulmonary dysplasia (BPD), the most common chronic 4 castle, Hunter Medical Research Institute lung disease of prematurity. Predictors of BPD include gestational age (GA), birth weight and respiratory support duration. These predictors are associated Introduction/Aim: High-flow warm humidified oxygen (HF WHO) is used with increased lung inflammation and oxidative stress, which are both key in extensively in paediatric practice in the absence of safety and efficacy data. BPD pathogenesis. Inflammatory and oxidative stress biomarkers in the pre- The primary aim of the clinical trial was to test whether HF WHO compared term lung can potentially be measured simply and non-invasively through to standard oxygen therapy reduced the median time on oxygen for infants the novel analysis of exhaled breath condensate (EBC). aged ≤24 months with moderate bronchiolitis. The present study aimed to establish feasibility of EBC collection in preterm Methods: We conducted an open, randomized control trial of HF WHO via infants, measure inflammatory and oxidative stress biomarkers in EBC and re- Optiflow Junior™ nasal cannula compared to cold low flow nasal cannula ox- late biomarker levels to neonatal factors. ygen therapy. Randomization was stratified for gestational history (extremely Methods: EBC was collected from very preterm infants (GA < 32 weeks premature, premature and term) and occurred in the Emergency Department (w)) aged 36 w postmenstrual age and 12–15 months corrected, with and or Medical Unit. Secondary outcomes were time to treatment failure and pro- without BPD. Inflammatory and oxidative stress markers were measured portion of treatment failure. Clinical significance was set at a reduction in time using enzyme-linked immuno-sorbent assay (ELISA) and liquid chromatogra- on oxygen of 12 h (0.5SD) from the historical median of 38 h for standard ther- phy/mass spectrometry (LCMS). Gas chromatography/mass spectrometry apyin2007(n = 160), which was the year before HF WHO was introduced into (GCMS) was used to examine EBC metabolomic profiles. our facilities. Results: EBC was successfully collected from 15 of 18 preterm infants. In- Results: Between July 2012 and May 2015, we recruited 202 infants with flammatory and oxidative stress markers were detectable in all EBC samples 101 assigned to each study arm. One hundred thirty-eight infants were males, using ELISA analysis. Lower levels of inflammatory marker leukotriene B4 and 64 were females. Mean (SD) age was 6.9 (±5) months. Baseline charac- were detected in infants with BPD compared to those without (p < 0.01), in- teristics were well balanced between the groups. Using intention to treat anal- fants with lower birth weights (p < 0.01), longer respiratory support ysis, the median time to weaning for standard therapy was 24 h (95% CI: 18 to (p < 0.01) and longer oxygen supplementation (p < 0.01). LCMS methods 28) and 20 h (95% CI: 17 to 34) for HF WHO, with a hazard ratio (HR) of 0.93 were optimized but remained too insensitive for EBC analysis. Differing (95% CI: 0.71 to 1.22, p = 0.61). Secondary outcomes demonstrated that in- metabolomic EBC profiles were identifiable between all infants using GCMS, fants on standard therapy failed sooner (HR = 0.29, 95% CI: 0.15 to 0.55, with all infants displaying possible alterations in surfactant metabolism and ox- p < 0.0001) and more frequently than on HF WHO (32.7% vs 14.9%, idative stress. p < 0.0029), respectively. HF WHO rescued 20/33 infants who deteriorated Conclusion: This is the first study to collect EBC in preterm infants. Pre- on standard therapy. term infants exhibit on-going inflammation and oxidative stress at 12– Conclusion: We detected no difference in time to weaning off supplemen- 15 months corrected age. EBC presents a non-invasive means to measure in- tal oxygen between the groups; however, HF WHO reduced the frequency of flammation and oxidative stress and perform metabolomic profiling. Further clinical deterioration and rate of transfer to intensive care. work is needed to overcome variable dilution and optimize EBC analysis. Key words: bronchiolitis, high-flow oxygen, infants, nasal cannulae, RCT Grant Support: Preterm Infant Functional and Clinical Outcome (PIFCO) Young Investigator Award Nomination study, NHMRC. Grant Support: Hunter Children’s Research Foundation; John Hunter Children’s Hospital Respiratory Charitable Trust; Registered with ANZCTR —no. ACTRN12612000685819.

TO 065 TO 066

REAL-TIME 3D AIRWAY RECONSTRUCTION FOR ANALYSIS CHILDREN WITH BRONCHIECTASIS HAVE REDUCED LUNG OF STRUCTURAL AIRWAYS DISEASE IN PAEDIATRIC FUNCTION AND POORER NUTRITIONAL STATUS THAN BRONCHOSCOPY THEIR CYSTIC FIBROSIS COHORT

WILSON S1,MASTERSB2,3,CHANGA2,3,4 PRENTICE B1,2,WALESS1,2,3,WIDGERJ1,2 1The Royal Brisbane and Women’s Hospital, Brisbane, Australia, 2Queens- 1Sydney Children’s Hospital, NSW, Australia, 2The Shcool of Women and land Children’s Medical Research Institute, University of Queensland, Children’s Health, The University of New South Wales, NSW, Australia, Brisbane, Australia, 3Department of Respiratory Medicine, Lady Cilento 3Faculty of Health, The University of Technology, Sydney, NSW, Australia Hospital, Brisbane, Australia, 4Child Health Division, Menzies School of Health Research, Darwin, Northern Territory Introduction/Aim: It is well recognized that patients with bronchiectasis are best managed in a multi-disciplinary team environment, as has been dem- Introduction/Aim: Structural airway disorders account for an increasing onstrated for patients with cystic fibrosis (CF). However, children and adoles- percentage of current paediatric respiratory practice and is often difficult to dis- cents with ‘non-cystic fibrosis’, bronchiectasis do not generally receive the tinguish from other disease entities without invasive investigations. The gold same level of care. The aim of his study was to compare lung function and nu- standard diagnostic tool is computed tomography (CT), which can produce tritional status in age and gender-matched bronchiectasis patients with CF static measurements of airway calibre and shape, at the expense of exposing patients. patients to potential harm from radiation. This paper presents a clinical soft- Methods: Retrospective analysis of bronchiectasis patients attending a ter- ware package for airway size analysis for diagnosing structural diseases. tiary paediatric centre between 2010 and 2015. Aetiology of bronchiectasis in- Methods: A software package has been developed to provide the ability to cluded post-infective bronchiectasis, bronchiectasis secondary to aspiration perform real-time and offline image processing of standard bronchoscopy im- or trachea-oesophageal fistula or primary ciliary dyskinesia. Patients were ages, producing a partial 3D reconstruction of the visible airway using a mod- matched by age and gender with CF patients attending the same centre. Lung ified shape from shading algorithm. The resulting 3D mesh was compared function and nutritional status data were collected. Lung function was per- using a mesh similarity algorithm with CT data obtained immediately prior to formed according to ATS criteria. Comparison of means between groups bronchoscopy. Sequential analysis provides the ability to measure airway was made using an unpaired T-test. changes over the respiratory cycle, which is not practical using CT imaging. Results: Results: Ten paired CT and bronchoscope examinations were used in this initial proof-of-concept test. Half of these examinations were taken from chil- Cystic dren with known structural abnormalities and half from normal examinations, Bronchiectasis ﬁbrosis p value performed for other indications. 3D reconstructions were measured at five locations in each bronchoscopy throughout the airway and compared to 3D Mean age (years)FEV1 % 10.377.15 9.997.75 0.780008* mesh data obtained from CT. The shape error between CT and bronchoscopy predictedn =20 ± 21.5 ±13.31 was below 5% for 42 of the 50 obtained meshes, with the remaining 8 (16%) FVC %predictedn =20 85.25 ± 15.58 103.37 0.0001* producing erroneous reconstructions due to mucous interference or signifi- ±11.69 cant airway structural problems, all of which were correctly identified by the FEV1/FVCn =20 system prior to measurement. 78.6 ± 15.93 83.3 ± 8.62 0.25 Conclusions: These early results indicate this system provides a viable BMI z scoren =22 -0.895 ± 1.5 -0.21 0.077 method for 3D reconstruction of the paediatric airway, and for the meaningful ±0.97 analysis of this information. While not intended to replace CT imaging, particularly for distal airways, this method provides another tool for assessing and managing paediatric structural airway disease, as well as various other forms of endoscopic examination in both paediatric and adult populations. Values are mean ± standard deviation. Grant Support: SW: Royal Children’s Hospital Foundation scholarship *statistically significant p < 0.05. (2006–2007). Conclusions: This cohort of paediatric patients with bronchiectasis had significantly reduced lung function than their CF-matched cohort. Nutritional status was poorer but not statistically different. This may have been due to the small cohort investigated. Given the severity of illness identified in the bronchiectasis group, it is likely that this cohort would benefit from a multi-disciplinary team approach to their management. Grant Support: NIL Declaration of Interest Statement: NIL

TO 068 Asthma 2 Oral Presentations

MICRORNAS EXPRESSION ABNORMALITIES IN ASTHMATIC EPITHELIAL CELLS TO 067 MOHEIMANI F1,2, KOOPS J1,2,3, WILLIAMS T1,2,5,RIEDA1,2,WARKP2,4, KNIGHT D1,2,5 1School of Biomedical Sciences and Pharmacy, University of Newcastle, TRANSFORMING GROWTH FACTOR ALPHA EXPRESSION IN Callaghan, NSW, Australia, 2Priority Research Centre for Asthma and Respi- A TRANSGENIC MOUSE MODEL IMPAIRS LUNG AND ratory Disease, Hunter Medical Research Institute, The University of Newcas- DIAPHRAGM MECHANICS tle, New South Wales, Australia, 3Department of Molecular Pharmacology, University of Groningen, Groningen, The Netherlands, 4Department of Respi- 1 2 3 1 2 ratory and Sleep Medicine, John Hunter Hospital, New South Wales, Austra- WANG K , ASTELL C ,WIJESINGHEP , LARCOMBE A , PNINNIGER G , 5 KENNEDY B3,ZOSKYG1,4, SAMPSON D3,5,JAMESA6,LECRAST7, lia, Department of Anesthesiology, Pharmacology and Therapeutics, NOBLE P1,2,8 University of British Columbia, Vancouver, Canada 1Telethon Kids Institute, 2School of Anatomy, Physiology and Human Biology, University of Western Australia, 3Optical + Biomedical Engineering Labora- Introduction/Aim: Specific microRNAs (miRs) are proposed to be key epi- tory, School of Electrical, Electronic and Computer Engineering, University genetic factors responsible for epithelial cell structural and functional abnor- of Western Australia, 4School of Medicine, University of Tasmania, 5Centre malities of asthmatic. We hypothesize that the level of miRs regulating for Microscopy, Characterisation and Analysis, University of Western proliferation (e.g. miR17-92 cluster), differentiation (e.g. miR-22 and -203) or Australia, 6Centre for Microscopy, Characterisation and Analysis, University innate/adaptive immunity (e.g. miR-132) is differentially expressed in asth- of Western Australia, 7Division of Pulmonary Biology, Cincinnati Children’s matic epithelium and play essential roles in epithelial cell abnormalities. Fur- Hospital Medical Centre, 8Centre for Neonatal Research and Education, ther, we suggest that expression of these miRs is further dysregulated by School of Paediatrics and Child Health, University of Western Australia virus infection and restored by exposure to β-agonists. Our aims are to determine the level of these miRs in primary bronchial epithelial cells (pBEC) of Introduction/Aim: Transforming growth factor alpha (TGFα) is increased asthmatics and non-asthmatics (a) at rest, (b) following influenza infection β in the lung tissue of patients with chronic respiratory disease. Animal models and (c) following exposure to short-acting agonists. show that deficiency in the early growth response (Egr-1) gene accelerates Methods: pBEC from severe asthmatic and non-asthmatic subjects were α obtained from bronchial brushing and cultured under submerged conditions. the disease process. The aim of this study is to examine the effects of TGF 6 on lung and diaphragm mechanics. Cells were incubated with H1N1 (pfu 1 × 10 ), UV-inactivaed H1N1 or μ Methods: Doxycycline produced conditional expression of TGFα in the air- salbutamol (10 M). miRNA was isolated using RNAeasy mini kit and sub- À jected to Taqman miRNA assays to assess expression of each miR. Expres- ways of transgenic mice (Clara cell secretory protein-rtTA(+/ )/[tetO](7)- -ΔΔct TGFα(+/À)) heterozygous for the Egr-1 gene. Four-week old mice were fed sion levels were quantified using the 2 method. doxycycline in chow (Dox) or a control diet (control) for 3 weeks. Lung me- Results: Basal expression of miR-17-5p was significantly lower in asth- chanics were assessed in anaesthetized and mechanically ventilated mice matic epithelium. There was a trend for reduced expression of miR-203 and by the forced oscillation technique. Separate groups of mice were euthanized -20a in epithelium of asthmatics, but this did not reach statistical significance. and the diaphragm removed for ex vivo study. Specific diaphragmatic force H1N1 infection had no effect on expression of any of these miRs over time (0, was measured in an organ bath and transverse elastance measured by opti- 4, 6 and 24 h). There was a trend towards an increase in expression of miR- cal elastography. 20a,-17-5p and -203 after incubation with salbutamol. Expression of miR-17- Results: Fibrosis was identified in the lung pleura, peribronchial space and 5p and -20a remained consistently lower in asthmatic epithelial cells, and this diaphragm with associated thickening of the central tendon. Lung elastance was not changed by time or treatment. (P = 0.02), tissue damping (P =0.01)andairwayresistance(P = 0.02) at func- Conclusions: Some miRs are expressed abnormally in epithelial cells β tional residual capacity were increased in the Dox group (n = 12) compared from severe asthmatics. Short-acting agonist treatment may further restore with control (n = 7). Specific diaphragmatic force fell with increasing collagen the expression of miRs regulating proliferation in asthmatic epithelium, within the muscle layer (r = À0.77, P = 0.001, n = 16). Transverse diaphragm whereas influenza infection showed no effect. — elastance was reduced (P = 0.04) in the Dox group (n = 10) compared with Grant Support: ECR and NS grants University of Newcastle, Fatemeh control (n = 8) suggesting fibrosis related dissociation of skeletal fibres. Moheimani. NHMRC project grant # 1064405, Prof Darryl Knight. Conclusion: Expression of TGFα impairs respiratory function characterized by increased lung loading and compromised diaphragm mechanics. Findings support a role of TGFα in chronic lung disease. Grant Support: NHMRC (1027218 and 1045824). Declaration of Interest Statement: None.

TO 069 TO 070

IDENTIFICATION OF NOVEL THERAPEUTIC TARGETS FOR A NOVEL EX VIVO PERFUSION SYSTEM FOR INVESTIGATING STEROID-INSENSITIVE ASTHMA USING MODELS THAT MUCOUS METAPLASIA IN MOUSE AIRWAYS REPRESENT DIFFERENT CLINICAL SUBTYPES OF DISEASE CHEAH E, MANN T, HENRY P HORVAT J1,KIMR1, PINKERTON J1,RAEB1, STARKEY M1,ESSILFIEA1, School of Medicine and Pharmacology, The University of Western Australia MAYALL J1,JONESB1,HAWT1,NGUYENH1, KEELY S1,MATTESJ1, 2 1 1 ADCOCK I ,FOSTERP , HANSBRO P Introduction/Aim: Excessive mucus production and hypersecretion are 1 2 University of Newcastle, National Heart and Lung Institute, Imperial College hallmark features of many airway diseases, including asthma, COPD and cys- London tic fibrosis. The underlying mechanisms are complex and require further investigation. Thus, the aim of the study was to develop a novel ex vivo Introduction: Steroid-insensitive (SI) asthma is of considerable clinical and perfusion system and evaluate its suitability for investigating mucous economic significance, and improved therapies are urgently required; how- metaplasia. ever, the development of therapies has been hampered by a lack of under- Methods: Tracheal segments were isolated from male BALB/c mice and standing of the pathological processes that underpin disease. The major cultured statically in sterile physiological media, or perfused with media to obstacle to understanding the processes that drive SI asthma is that several mimic dynamic flow conditions following exposure to lipopolysaccharide subtypes of the disease, characterized by different immunological and inflam- (LPS, 1 μg/mL, 1 h). Alternatively, segments were ventilated with humidified matory subtypes, exist. air. At selected points thereafter (2, 6, 18, 24, 48 h), segments were fixed Aim: Our aim is to develop experimental models of SI asthma that repre- and levels of epithelial mucus determined by quantitative analysis of periodic sent different subtypes of clinical disease and use these models to elucidate acid-Schiff’s reagent (PAS)-stained sections. PAS levels were determined by universal drivers of SI asthma. enumerating strong positive pixels within the epithelium (%SPP). Additionally, Methods: Mouse models of Chlamydia, Haemophilus, influenza and respi- organ bath studies were conducted to determine the impact of perfusion and ratory syncytial virus (RSV) lung infections were superimposed on a steroid- ventilation on the functional integrity of the epithelium and smooth muscle. sensitive model of ovalbumin (ova)-induced allergic airways disease (AAD). Results: Perfusion with media and ventilation with humidified air better pre- The effects of infection on immune and inflammatory responses in the lungs served epithelial morphology for up to 24 h when compared to static tissue cul- and response to dexamethasone (DEX) treatment were examined. ture. Importantly, media perfusion produced time-dependent increases in Results: We show that Chlamydia and Haemophilus infections increase levels of PAS staining (e.g. 9.1 ± 1.5 (SEM) %SPP at 18 h vs 1.1 ± 0.3% Th1 and/or Th17 responses and drive neutrophil-dominated inflammation, SPP at 0 h; n =7–8, p < 0.05), which was significantly enhanced by acute while influenza and RSV infections increase Th1 responses and drive eosino- LPS exposure (22.2 ± 3.6%SPP vs 9.1 ± 1.4%SPP; n = 5-8, p < 0.01). In con- phil-dominated inflammation, in AAD. DEX does not suppress inflammation or trast, ventilation with humidified air did not produce mucous metaplasia (2.3 airways hyper-responsiveness in all four models. These models of SIAAD rep- ± 0.4%SPP; n = 6). Contractile and relaxation responses of perfused and ven- resent neutrophil and eosinophil-enriched subtypes of SI asthma. Using gene tilated tracheal segments were also largely preserved to carbachol, the neuro- expression and microRNA (miR) array analyses of these models, we have peptide substance P, and the prostanoid PGE2. identified several factors that are universally dysregulated in SIAAD compared Conclusions: In our novel perfusion system, mucous metaplasia devel- to control groups with steroid-sensitive AAD. Significantly, we show that the oped in response to the flow of liquid (but not air) and was enhanced by acute targeted suppression of miR-21 is effective for restoring steroid sensitivity in LPS exposure. This system may serve as a useful model through which to in- all four models. vestigate mechanisms underlying mucous metaplasia or mucus secretory Conclusions: We have developed unique models of both neutrophilic and processes and to evaluate the efficacy of potential therapies that directly target eosinophilic SI asthma and used these models to identify factors that are uni- mucous metaplasia. versally dysregulated in SI disease. These factors may represent novel tar- Grant Support: National Health and Medical Research Council Australia. gets for therapeutic strategies that are broadly effective for the treatment of different subtypes of SI asthma in humans. Grant Support: NHMRC and HMRI. Conflict of interest: None.

TO 071 TO 072

UNDERSTANDING MECHANISMS OF BACTERIAL-INDUCED A SHEEP MODEL TO EXAMINE THE EFFECTS OF MATERNAL DISEASE EXACERBATION IN A MOUSE MODEL OF ALLERGIC ASTHMA ON FETAL OUTCOMES AIRWAYS DISEASE BISCHOF R1,2,CLIFTONV5,6, WOOLDRIDGE A5,GATFORDK5,LIRAVIB2, HADJIGOL S, MALTBY S, YANG M, FOSTER P KIM D2,MUHLHAUSLERB7,MORRISONJ8,DAVIESA2,9,DEMATTEOR4, University of Newcastle and Hunter Medical Research Institute WALLACE M1,3,MOSST1,3 1The Ritchie Centre, Hudson Institute of Medical Research, Clayton VIC 3168, 2 Introduction/Aim: Acute asthma exacerbations are commonly associated Australia, Department of Physiology, Monash University, Clayton VIC 3800, 3 with viral or bacterial infections and represent a significant health burden on Australia, Department of Obstetrics and Gynaecology, Monash University, 4 asthmatic patients. While most asthmatic patients respond well to standard Clayton VIC 3800, Australia, Department of Anatomy and Developmental 5 treatments (including corticosteroids), some patients fail to respond ade- Biology, Monash University, Clayton VIC 3800, Australia, Robinson quately, particularly during acute disease exacerbations. Our understanding Research Institute and School of Paediatrics and Reproductive Health, 6 of how infection-induced activation of innate immune pathways triggers ste- University of Adelaide, Adelaide SA 5005, Australia, Mater Medical Research 7 roid-resistant inflammation remains limited. We hypothesized that bacterial in- Institute, University of Queensland, Brisbane, Qld 4101, Australia, FOODplus fection (mimicked by LPS exposure) would exacerbate underlying allergic Research Centre, School of Agriculture, Food and Wine, The University of 8 airways disease, leading to steroid-resistant airways inflammation and hy- Adelaide, Adelaide SA 5005, Australia, Early Origins of Adult Health per-responsiveness. Using this model, we will assess new therapeutic ap- Research Group, School of Pharmacy and Medical Sciences, Sansom Insti- proaches to treat infection-induced exacerbation. tute for Health Research, University of South Australia, Adelaide SA 5001, 9 Method: Mice were sensitized and subsequently challenged with nebu- Australia, School of Biomedical Sciences, Peninsula Campus, Monash lized ovalbumin (OVA) to induce allergic airways disease. Some groups were University, Frankston VIC 3199, Australia also administered LPS to simulate bacterial infection, in the presence or absence of dexamethasone (DEX) to assess steroid sensitivity. Disease read- Introduction/Aim: Maternal asthma during pregnancy has an adverse ef- outs were assessed by measuring lung function, inflammation and fect on pregnancy outcomes, but identifying the cause(s) and the ability to inflammatory cell numbers and tissue cytokine and microarray profiling. evaluate interventions is limited by the lack of an appropriate animal model. Results: LPS administration increases steroid-resistant airway hyper-re- In this study, we developed a sheep model of maternal allergic asthma to ex- sponsiveness. In this model at day 24, IL27 and TNFa were increased and amine maternal responses and effects on foetal development. Dex resistant, while TH2 cytokines remained similar. Specifically, neutrophil Methods: Allergic asthma was induced in sheep using an established pro- and macrophage numbers were increased in bronchoalveolar lavage fluid tocol that included parenteral immunization prior to mating, followed by (BALF) following LPS administration. Targeted depletion of alveolar macro- chronic weekly airway challenges with house dust mite allergen (HDM) that phage with clodronate liposomes could partially suppress AHR. Microarray continued throughout pregnancy. Maternal and foetal lung and placental phe- profiling of lung revealed 81 and 254 genes that were up- and down-regulated, notypes were characterized in singleton-bearing ewes (allergic and non-aller- respectively. Further, seven microRNAs were also up-regulated. gic controls) at 138–142 d gestational age (term ~147 d). Conclusions: We have developed a novel mouse model of bacterial infec- Results: The eosinophil influx into lungs was greater after HDM challenge tion-induced asthma exacerbation that is insensitive to steroid treatment. Fur- in allergic ewes than after saline challenge in control ewes before mating and ther, our findings reveal a role for macrophages in disease development and in late gestation. Airway resistance increased throughout pregnancy in allergic identify unique gene expression changes within the lung during disease. but not control ewes, consistent with the accumulation of airway smooth mus- These data provide a new model and potential targets to explore the mecha- cle seen in allergic airways. Maternal allergic asthma decreased relative foetal nisms underlying severe disease exacerbation in asthma. weight (À12%) and altered placental phenotype to a more mature form. In foe- Key words: asthma, exacerbation, innate immunity, lipopolysaccharide, tal lungs, expression of surfactant protein (SP) -B mRNA was 48% lower in macrophage, microRNA foetuses from allergic ewes than controls, with a similar trend for SP-D. Thus, Nomination for Young Investigator Award allergic asthma in pregnant sheep modifies placental phenotype and inhibits Grant Support: NHMRC project funding. foetal growth and lung development consistent with observations from human pregnancies. Conclusions: This study for the first time establishes a large animal model of maternal asthma, based on allergen sensitization prior to conception followed by repeated airway challenges in pregnant sheep, that can be used to investigate mechanisms of altered foetal development and adverse pregnancy outcomes caused by maternal asthma in pregnancy.

TO 074 Respiratory Infectious Diseases 1 Oral Presentations

MICROBIAL DIVERSITY AND ABUNDANCE IN RESPIRATORY DISEASE AND HIV IN CHILDREN FROM MOZAMBIQUE TO 073 ANNAMALAY A1,JAMESP2, LANASPA M3,4, BIZZINTINO J1, ACÁCIO S3, MADRID L3,4,BASSATQ3.4,MOFFATTM2,LESOUËFP2, COOKSON W2 1School of Paediatrics and Child Health, The University of Western Australia, ESTIMATING THE RECURRENCE RATE OF TUBERCULOSIS 2National Heart and Lung Institute, Imperial College, London, UK, 3Centro de AND MORTALITY AMONG SMEAR POSITIVE PATIENTS Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, TREATED BY THE NATIONAL TUBERCULOSIS PROGRAM IN 4ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic— VIETNAM Universitat de Barcelona, Barcelona, Spain

FOX G, NHUNG N, ANH N, HOA N, LIEU P, NGOC ANH L, LOI N, CUONG Introduction/Aim: Despite growing interest in human microbiome re- P, BRITTON W, MARKS G search, little is known about the respiratory microbiome in acute lower respira- University of Sydney tory infections (ALRI) or HIV in children in Africa. The aim of this study was to compare the microbial diversity and abundance in oropharyngeal specimens Introduction/Aim: The recurrence rate of tuberculosis (TB) is an important from children: with and without ALRI; with and without HIV and with and with- indicator of the effectiveness of a TB control program. Throughout Vietnam, out respiratory viruses from both the hospital and community in Manhiça, 7% of all notified TB patients treated by the National TB Program (NTP) have Mozambique. recurrent TB. This may underestimate the true recurrence rate, as it does not Methods: DNA was extracted from oropharyngeal throat swabs collected capture patients lost to follow-up. We aimed to determine the TB recurrence from 98 hospitalized ALRI cases and 96 non-ALRI community controls less – rate and mortality among patients with smear positive TB treated by the than 10 years of age. The V3 V5 variable region of the 16S rRNA gene was NTP in the first 24 months or more of follow-up. amplified and sequenced using the Illumina MiSeq Platform. Methods: This prospective cohort study, with nested case–control study, Results: Streptococcus was the most abundant genus identified in children was conducted in 70 districts selected at random from eight provinces in Viet- with and without ALRI and with and without HIV. There were no differences in nam. Adult patients with smear positive pulmonary tuberculosis, enrolled in a overall diversity of microbial populations between hospital cases and commu- cluster-randomized controlled trial of household contact investigation, were nity controls (Shannon index (t(192.6) = 0.29, p = 0.78) and Simpson index (t À re-traced for between 2 and 4 years after treatment initiation, and recurrent (190.3) = 0.25, p = 0.80)) or between HIV-infected and HIV-uninfected À episodes of TB and mortality were documented. In addition, patients with ALRI-cases (Shannon index (t(16.2) = 1.21, p = 0.24) and Simpson index À incident TB, and a random sample of healthy contacts, were invited to (t(20.3) = 2.00, p = 0.06)). Several operational taxonomic units (OTUs) were complete a detailed questionnaire. differentially abundant between: ALRI cases and controls; HIV-infected and Results: Overall, 10 973 patients with smear positive TB were enrolled at HIV-uninfected cases; pneumonia and bronchiolitis cases and cases with 70 District TB Units between 1 September 2010 and 31 July 2013. Among and without respiratory viruses. For HIV and respiratory viruses, the vast ma- these, 9949 (90.7%) were re-traced after a median period of 34 months (inter- jority of differentially abundant OTUs were more abundant among the virus- quartile range 28–40 months). During treatment, 3.3% died. Among 9354 pa- negative ALRI cases than among the virus-positive ALRI cases. tients who completed treatment, 549 (5.9%) developed recurrent TB during Conclusions: Fewer OTUs are more abundant among HIV and respiratory follow-up. Among re-traced patients, 1085 (9.9%) died either during treatment virus-infected children compared with HIV and respiratory virus-uninfected or follow-up. The crude annual mortality rate was 3.5% deaths per year of fol- children. Different bacteria (even within the same genus) may have varied low-up. Among the 720 deaths during the follow-up period, 241 (33.5%) pathogenic roles, and some may even be protective or involved in synergistic deaths were attributed to TB. The age and gender standardized mortality ratio relationships protecting against respiratory disease and HIV. for TB patients compared to household contacts was 5.9. Grant Support: Bill and Melinda Gates Foundation, Wellcome Trust, NIHR Conclusions: The mortality rate of TB among smear positive patients was Respiratory Disease Biomedical Research Unit, NHMRC, APA, UWA Safety substantial. Further research is required to identify factors associated with Net and AFWA Top-Up Scholarships. mortality, to further strengthen TB control in Vietnam.

TO 075 TO 076

PROGRAMMED DEATH-1 (PD-1) PREDISPOSES TO ALVEOLAR MACROPHAGE FUNCTIONS ARE ALTERED RESPIRATORY VIRAL INFECTION-INDUCED SECONDARY DURING PREGNANCY AND CAUSE AN INCREASED BACTERIAL PNEUMONIA SUSCEPTIBILITY TO INFLUENZA INFECTION

HANSBRO P1, BROWN A1,ESSILFIEA1, BECKETT E1,THORBURNA1, LAUZON-JOSET J, SCOTT N, MINCHAM K, HOLT P, STRICKLAND D HANSBRO N1,JARNICKIA1,YAGITAH2,FOSTERP1,HORVATJ1 Telethon Kids Institute, Cell Biology Division, Perth (WA), Australia 1Hunter Medical Research Institute, University of Newcastle, 2Department of Immunology, Jutendo University, Tokyo, Japan Introduction/Aim: Influenza is a common respiratory infection that affects between 5% and 10% of the adult worldwide population annually. A significant Introduction/Aim: Secondary bacterial pneumonia frequently occurs fol- risk factor for increased susceptibility to influenza infection, discovered almost lowing several different respiratory viral infections, including respiratory syncy- a century ago, is pregnancy. Furthermore, pregnant women are more prone to tial virus and influenza. Studies have demonstrated that many components of developing worse symptoms compared with the general population. Influenza the immune response are dysfunctional during secondary bacterial infections. infection during late pregnancy can have severe health complications for both Anti-inflammatory processes such as the PD-1/PD-Ligand (PD-1/PD-L) path- the mother (hospitalization and even death) and the foetus (low birthweight, way may be involved and targeted to improve responses to secondary bacte- preterm delivery and stillbirth). However, little is known in regard to the im- rial infections. The aim of this study is to determine whether the immuno- mune response occurring in the gestational tissues during influenza infection suppressive PD-1/PD-L pathway is commonly upregulated during different re- that lead to pregnancy complications. Although the immune system is a com- spiratory viral infections, and can alter immune responses, predisposing to plex network of immune cells, alveolar macrophages (AM) are strongly asso- secondary bacterial pneumonia ciated with lung homeostasis and protection from influenza infection. Given Methods: We have developed two mouse models of respiratory viral infec- that influenza infection is more severe during pregnancy, the hypothesis of this tion followed by secondary bacterial infection. Mice were infected with pneu- project is that AM functions are dysregulated during pregnancy, and this leads monia virus of mice (PVM) or influenza; then at viral clearance, mice were to increase severity of influenza infection. infected with Streptococcus pneumoniae. PD-1/PD-L expression and immune Methods: BALB/c mice were time-mated and fed OM-85BV once a day cell profiles of the lung were analysed by flow cytometry. The role of PD-1/PD- from gestational day (GD) 0.5 until GD8.5. Mice were infected with a low dose L was determined by administration of a PD-1 blocking antibody. of H1N1 influenza A virus (mouse adapted PR8 strain) at GD9.5 (correspond- Results: Respiratory bacterial titres in secondary S. pneumoniae infections ing to mid-late gestation). AM will be collected by BAL and transferred in AM- were increased compared to a primary S. pneumoniae infection. Cellular pro- depleted (with Clodrosome 3 days prior) mice. files from each model demonstrated similar alterations in macrophage re- Results: The first objective of this project is to determine whether preg- sponses, increases in activated T-cells, and elevated PD-1 and PD-L1 nancy alters AM functions (including, phagocytosis, as well as immune polar- expressing cells. Blocking PD-1 signalling reduced respiratory bacterial titres ization (M1/M2) and cytokine productions). Then, AM of pregnant mice will be during both secondary infection models. transferred to non-pregnant mice, and we will asses the severity of disease, as Conclusion: Prior PVM or influenza infection induces similar immune cell well as the immune responses. profiles and an upregulation of the PD-1/PD-L pathway that may suppress im- Conclusion: This project will give new insight on the impact of pregnancy munity to a secondary bacterial infection. Blocking this commonly upregulated on disease susceptibility and the role of AM on the worsening of influenza in- pathway may be a potential novel therapy for secondary bacterial infection. fection during pregnancy. Grant Support: NHMRC Project Grant and HMRI Greave’sFamilyRe- Grant Support: OM Pharma, Wesfarmer Centre of Vaccines and Infec- search Higher Degree Support Grant. tious Diseases. Conflict of Interest: N/A.

TO 076a TO 076b

ADHERENCE TO NATIONAL GUIDELINES FOR THE INTRAPLEURAL THERAPY USING TPA 5MG (WITH DNASE) IS INPATIENT MANAGEMENT OF PNEUMONIA AND COPD, AN EFFECTIVE ALTERNATIVE TO TPA 10MG (WITH DNASE) BEFORE AND AFTER AN EDUCATIONAL INTERVENTION AT FOR PLEURAL INFECTION AN AUSTRALIAN TERTIARY HOSPITAL POPOWICZ N1,2,3,BINTCLIFFEO5, PICCOLO F6, D WONG4,EDEYA7, THIRUVARUDCHELVAN A1,THOMSONC2,NUNEZN2,3,WONGK2,3, MASKELL N5, LEE YCG1 TORZILLO P2,,TROYL1 1School of Medicine & Pharmacology, University of Western Australia, Perth, 1Department Respiratory and Sleep Medicine, Royal Prince Alfred Hospital Australia, 2Institute for Respiratory Health, Perth Australia, Institute for Respi- Camperdown, NSW, Australia, 2Department of Respiratory and Transplant ratory Health, Perth Australia, 3Pharmacy and 4Respiratory Department, Sir Medicine, St Vincent’s Hospital, Darlinghurst, NSW, Australia, 3Sydney Chil- Charles Gairdner Hospital, Perth, Australia, 5Academic Respiratory Unit, dren’s Hospital, Randwick, NSW, Australia, 4Sydney Medical School, Univer- School of Clinical Sciences, University of Bristol, Bristol, UK, 6Department of sity of Sydney, Sydney, NSW, Australia, 5Woolcock Institute of Medical Medicine, Swan District Hospital, Perth, Australia, 7Department of Radiology, Research, Glebe, NSW, Australia North Bristol NHS Trust, Bristol, UK Introduction/Aim: The emergence of multi-resistant organisms has been Introduction/Aim: Intrapleural therapy with 10mg tPA and 5mg DNase has linked to injudicious antibiotic prescribing. We aimed to measure the effect been shown to successfully manage most (>93%) patients with pleural infec- of an educational intervention on recommended antibiotic guidelines in tion in a randomized trial (NEJM 2011) and in our longitudinal series (Ann ATS Chronic Obstructive Pulmonary Disease (COPD) and Community Acquired 2014). The current dosage recommendations are based on empirical “best Pneumonia (CAP), by comparing pre- and post-intervention rates of guideline guesses”. Employing a lower dose of tPA may reduce complications and cut adherence. treatment costs by $1500/patient. Methods: Data was collected from all admissions to the Respiratory Unit of an Methods: This two-center study included 27 consecutive patients with pleural Australian tertiary hospital for CAP and infective/ non-infective exacerbations infection (18 male; mean age 55±15) from Perth, Australia and Bristol, UK. of COPD over a 6 month period, (Oct 2013 to Mar 2014, Audit Period 1). Pa- Patients who failed to respond to chest-tube drainage and antibiotics were tient demographics, antibiotic prescribing choices, length of hospital stay given intrapleural tPA (5mg) with DNase (5mg) twice-daily, and their clinical (LOHS) and in-hospital mortality were recorded. Following Audit Period 1, a data recorded prospectively. one-hour education session was given to Emergency and Respiratory Depart- Results: Most (92.6%) patients were successfully treated using tPA (5mg) ment staff. The session detailed the rationale for prescribing within guidelines with DNase without surgery and survived until hospital discharge. tPA/DNase and provided direct feedback to prescribers on adherence to national recom- was administered a median of 2 days (IQR 1-3) after chest-tube insertion. The mendations during Audit Period 1. Data was then collected for a second 6- amount of fluid drained in the 24hrs preceding intrapleural treatment was month period (Apr 2014 to Sep 2014, Audit Period 2). Rates of concordance 200mL (IQR 100-500), which increased to 2490mL (IQR 1675-3325) in the with guidelines for the two audit periods were compared using chi-squared 72hrs from starting therapy. This was paralleled by a significant reduction in tests for independent proportions. radiographic opacity by a median value of 38% (IQR 14-48) of the hemithorax. Results: Audit Period 1 included 111 patients (53 males, 69.8 ± 13.4yrs, 68 C-reactive protein decreased by 40% from baseline on day 4 of treatment. with COPD, 43 with CAP, mean LOHS 7.3 ± 5.3days, 1 in-hospital death). Au- Pain was common (52%) following the initial dose of tPA/DNase and was dit Period 2 included 151 patients (92 males, 68.6 ± 14.8yrs, 83 COPD pa- managed with opioid analgesia. No systemic bleeding occurred. Three patients, 67 with CAP, mean LOHS 7.6 ± 7.0days, 0 deaths). Following the tients required blood transfusions for decreasing hemoglobin level; all were intervention, guideline adherence in prescribing for COPD patients improved haemodynamically stable. One patient (87/male) died from his underlying from 42% to 75% (p<0.0001). In CAP patients, the increase in appropriate an- pneumonia, one (57/male) required surgical decortication and another re- tibiotic prescriptions (from 16% to 40%) was also significant (p=0.01). LOHS quired escalation of tPA dose. and mortality were not significantly different between the two periods in either Conclusion: This pilot study found that treatment with 5mg tPA (with 5mg DNase) COPD or CAP patients. appeared comparable in efficacy as the 10mg tPA/5mg DNase regimen. Conclusion: Although adherence to antibiotic prescribing guidelines in Direct comparison studies are warranted. COPD and CAP patients were suboptimal throughout the study, there was a Grant Support: Institute for Respiratory Health, WestCare Grant. significant increase in recommended prescribing with a single educational Declaration of Interest Statement: Nil. intervention.

TO 078 Chronic Obstructive Pulmonary Disease 2 Oral Presentations SLEEP QUALITY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE REFERRED FOR PULMONARY REHABILITATION

TO 077 ROBERTS M1,CHOJ1,2,3, WHEATLEY J1,2,3 1Westmead Hospital, 2Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, 3University of Sydney at Westmead Hospital LOW COST HOME-BASED PULMONARY REHABILITATION FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE: A Introduction: Chronic obstructive pulmonary disease (COPD) is a com- RANDOMIZED CONTROLLED EQUIVALENCE TRIAL mon chronic lung disease with both daytime and nighttime symptoms such as cough and breathlessness and is associated with poor quality of life. In ad- 1,2,3 4 3,5 2,3 1,2,3 1,3 dition, patients with COPD often report poor sleep quality regardless of the HOLLAND A ,MAHALA,HILLC ,LEEA , BURGE A ,COXN , presence or absence of underlying sleep disorders. MOORE R5,NICOLSONC1,2,O’HALLORAN P1,LAHHAMA1,3, NDONGO 1,5 3,6,7 Aims: Our aim is to determine (i) the prevalence of poor sleep quality (Pitts- R ,MCDONALDC burgh Sleep Quality Index (PSQI) ≥ 5 a.u.) in patients with COPD referred for 1Physiotherapy, La Trobe University, 2Physiotherapy, Alfred Health, 3Institute 4 pulmonary rehabilitation (PR) and (ii) the factors associated with poor sleep for Breathing and Sleep, Epidemiology and Preventive Medicine, Monash quality. University, 5Physiotherapy, Austin Health, 6Respiratory and Sleep Medicine, 7 Methods: We had a retrospective chart review of COPD patients assessed Austin Health, Medicine, The University of Melbourne for PR in Western Sydney over an 18-month period. Associations between sleep quality (PSQI) and continuous physiological and symptom-based Introduction: Pulmonary rehabilitation (PR) is a cornerstone of care for COPD variables were made using Pearson’s correlations. Categorical COPD chronic obstructive pulmonary disease (COPD), but global access and uptake variables were examined using one-way analysis of variance. Data were are poor. This study aimed to determine whether low cost home-based PR de- expressed as mean ± SD, and p < 0.05 was significant. livered equivalent outcomes to traditional centre-based PR. Results: Sleep quality data were available for 337 patients: 51% male; age Methods: We conducted a randomized controlled equivalence trial with as- 69.5 ± 9.2 years; FEV1 46 ± 17% predicted; body mass index 27.7 ± 7.7 kg/ sessor blinding and 12 months follow-up. Participants with stable COPD m2; Epworth sleepiness scale 5.9 ± 4.5 a.u. Poor sleep quality was experi- (n = 166, mean FEV1 50 (SD 19) %predicted) received 8 weeks of PR, deliv- enced by 267 patients (80%; PSQI 8.5 ± 4.5 a.u.). Univariate analyses ered either by a standard outpatient centre-based model or a home-based PR showed positive correlations between PSQI and St George Respiratory Ques- model which consisted of one home visit and seven once-weekly telephone tionnaire (r =0.35, p < 0.001), Hospital Anxiety and Depression Scale calls using a motivational interviewing approach. The primary outcome was (r = 0.40, p < 0.001 for anxiety; r =0.28,p < 0.001 for depression), modified change in 6-min walk distance (6 MWD). Detailed documentation of direct pro- Medical Research Council dyspnoea scale (r =0.24,p < 0.001) and COPD gram costs was undertaken. Assessment Test (r =0.36,p < 0.001). There were weaker negative correla- Results: There were no significant between-group differences in clinical tions between sleep quality and age (r = À0.13, p < 0.02). outcomes at any time point. The change in 6 MWD post-intervention con- Conclusions: In a PR program, there was a high prevalence of non-sleepy firmed non-inferiority of home-based PR, and the confidence interval (CI) did COPD patients with poor sleep quality. Factors which were associated with not rule out superiority (mean difference between groups 18.60 m, 95% CI poor sleep quality include anxiety, depression, poorer quality of life, breath- À 3.55 to 40.71 m). At 12 months, the CI did not exclude inferiority of home lessness, reduced exercise tolerance and COPD symptoms, but not mea- À À PR ( 5.14 m, 29.40 to 19.13 m). Dyspnoea-related quality of life on the sures of COPD severity or lung function. Further studies are required to chronic respiratory questionnaire was non-inferior following rehabilitation explore causal links between COPD and poor sleep quality. À and superiority of home PR could not be excluded (1.57 units, 0.34 to 3.48 Grant support: Nil. units), whilst results were equivalent at 12 months (À0.10 units, À2.16 to 1.97 units). Neither group had maintained post-rehabilitation gains at 12 months. Costs of delivery were $312 for hospital PR and $298 for home- based PR. Conclusions: Low cost home-based PR delivers short-term clinical outcomes that are at least equivalent to traditional centre-based pulmonary rehabilitation programs, but neither model maintained these gains at 12 months. Home-based PR could be considered for people with COPD who cannot access centre-based PR programs. Grant Support: Lung Foundation Australia, National Health and Medical Research Council (1046353).

TO 079 TO 080

LIMITED RECOMMENDATIONS WITHIN COPD CLINICAL AN INTERDISCIPLINARY MODEL OF CARE FOR THE EARLY PRACTICE GUIDELINES CONCERNING OPTIMISING DETECTION AND MANAGEMENT OF CHRONIC OBSTRUCTIVE PHYSICAL ACTIVITY, SEDENTARY BEHAVIOUR AND SLEEP: PULMONARY DISEASE (COPD) IN PRIMARY CARE—THE A SYSTEMATIC REVIEW RADICALS© TRIAL

LEWTHWAITE H1,EFFINGT2,3,OLDST1,WILLIAMSM1 LIANG J1,ABRAMSONM2,ZWARN3,RUSSELLG4,HOLLANDA5, 1Alliance for Research In Exercise, Nutrition and Activity, School of Health Sci- BONEVSKI B6,MAHALA2, VAN HECKE B7,PHILLIPSK8, SHARP D9, ences, University of South Australia, South Australia, 2Department of Respira- PETRIE K1,WILSONS1, GEORGE J1 tory Medicine, Southern Adelaide Local Health Network, South Australia, 1Centre for Medicine Use and Safety, Monash University, 2Epidemiology and 3School of Medicine, Flinders University, South Australia Preventive Medicine, Monash University, 3Public Health and Community Medicine, University of New South Wales, 4PrimaryHealthCare,MonashUni- 5 6 Introduction/Aim: Physical activity, sedentary behaviour and sleep have versity, Physiotherapy, La Trobe University, Medicine and Public Health, 7 8 strong associations with health. This systematic review aimed to identify University of Newcastle, Boehringer Ingelheim Pty Ltd, Lung Foundation 9 recommendations and strategies reported in clinical practice guidelines for of Australia, Eastern Melbourne Primary Health Network COPD for adopting and maintaining optimal physical activity, sedentary behaviour and sleep. Aim: Up to 50% of smokers may develop clinically significant COPD. De- Method: A systematic search of databases (Medline, Scopus, CiNAHL, spite dissemination of evidence-based guidelines, there is still under-diagno- EMbase and clinical guildine) identified current versions of evidence-based sis and under-management in Australian primary care. We describe the clinical practice guidelines for the management of COPD created by implementation and evaluation of an interdisciplinary model of care-RADI- authorative bodies published in English. Studies published from 2005 to pres- CALS© (Review of Airway Dysfunction and Interdisciplinary Community- ent were sought. Primary data regarding recommendations (frequency, dura- based care in Adult Long-term Smokers) for reducing the burden of smoking tion, intensity and type) and strategies for adopting and maintaining optimal and COPD in patients attending general practices. physical activity, sedentary behaviour and sleep were extracted verbatim Methods: Cluster randomized controlled trial evaluating the RADICALS© and synthesized into common categories. intervention. General practice clinics have been identified and randomized. Results: Twenty clinical guidelines (from 2379 citations identified) were el- Current and ex-smokers (aged ≥ 40 years, ≥10 pack years), with or without igible for inclusion. All guidelines recommended pulmonary rehabilitation an existing diagnosis of COPD are being recruited to identify 280 with COPD. (PR); however, only 11 recommended physical activity outside the PR pro- The handheld COPD-6® is used to facilitate case-finding; those with FEV1/ gram and reported optimal frequency (n = 7), duration (n = 2), intensity FEV6 ≤ 0.75 are referred for spirometry. The intervention includes individual- (n = 1) and type (n = 3). No guideline provided recommendations for optimal ized smoking cessation support, home-based pulmonary rehabilitation and sedentary behaviour or sleep. Strategies to adopt or maintain optimal behav- home medicines review. Control group participants receive Quitline® referral iours were reported for physical activity (n = 16), sedentary behaviour (n =2) and usual care. Follow-ups occur at 6 and 12 months from baseline to assess and sleep (n = 4). Physician encouragement (physical activity n =8,sedentary changes in quality of life, abstinence rates, health resource utilization, symp- n = 1), education (physical activity n =6,sedentaryn = 1) and supplemental tom severity, physical activity and lung function. oxygen (physical activity n =5,sleepn = 3) were the most frequently reported Results: Twenty-eight clinics across Victoria have been randomized; 362 strategies. patients have consented to the trial. COPD-6® testing has occurred in 314 Conclusions: Current evidence-based clinical practice guidelines for the patients with 34 COPD cases confirmed using spirometry. RADICALS© is management of COPD do not have consistent recommendations for optimal being delivered and 6-month follow-ups have commenced in some clinics. physical activity, sedentary behaviour or sleep. While all guidelines recom- Participant recruitment is expected to be complete by the end of 2015. mend referral to PR, there is inconsistency amongst guidelines for effective Conclusions: Case-finding using handheld devices measuring FEV1 and strategies to optimize physical activity, and no guideline provides strategies FEV6, followed by spirometry is feasible in primary care. However, the propor- to optimize sedentary behaviour or sleep. It is difficult to include detailed infor- tion of participants found to have COPD was lower than previously reported. mation on all aspects of COPD management in a single management guide- Challenges in practice and participant recruitment may have influenced the line; however, optimizing use of time should be an important focus given the rate of COPD in this population. associated health benefits. Grant Support: NHMRC, Cyril Tonkin Scholarship, Boehringer Ingelheim Key words: evidence-based clinical practice guideline, physical activity, (BI). sedentary behaviours, sleep Declaration of Interest Statement: Nil conflict of interest to disclose.

TO 081 TO 082

LOWER CHILDHOOD LUNG FUNCTION PREDICTS MIDDLE- COMPARISON OF PHARMACOLOGICAL VERSUS AGE COPD AND ASTHMA-COPD OVERLAP SYNDROME PSYCHOLOGICAL THERAPIES FOR MANAGEMENT OF ANXIETY IN COPD PATIENTS BUI D1,BURGESSJ1,LOWEA1,LODGEC1, PERRET J1, ABRAMSON M2, STEPHEN M3,PAULT4, WALTERS H1,MATHESONM1,DHARMAGES1 USMANI Z1,3, CARSON K2,3, SMITH B1,3 1University of Melbourne, 2Monash University, 3University of Queensland, 1The Queen Elizabeth Hospital, South Australia, 2Clinical Practice Unit, Basil 4University of New South Wales Hatzel Institute, South Australia, 3School of Medicine, University of Adelaide

Introduction/Aim: The role of childhood lung function in adult COPD and Introduction/Aim: Rates of anxiety in patients with COPD range from 13% asthma-COPD overlap syndrome (ACOS) is not fully understood. We investi- to 51%, which is higher than rates for patients with heart failure and cancer, yet gated these associations using data from the Tasmanian Longitudinal Health evidence underpinning the effectiveness of the various treatment options is Study. lacking. As such, the aim of this study was to assess the efficacy and safety Method: Pre-BD spirometry was performed in a population-based cohort of of pharmacological and psychological interventions for the management of 7-year-old school children in 1968. When subjects were 44 years, a sub-sam- anxiety in COPD. ple had pre- and post-BD spirometry. Overall, 1372 subjects with lung function Methods: We searched two Cochrane Specialised Registers with comple- data at both 7 and 44 years were included in this analysis. Current asthma mentary screening of Medline, PsycINFO and CENTRAL. Reference lists of was defined as having asthma plus any asthma symptom or asthma medica- included studies and online clinical trial registries were also screened. Ran- tion use in the last 12 months. COPD was defined as post-BD FEV1/ domized controlled trials (RCTs) and cross-over studies of pharmacological FVC < lower limit of normal (LLN) at 44 years. ACOS included subjects with or psychological interventions for patients (age >40 years) with diagnosed both COPD and current asthma. Global Lung Initiative reference equations COPD and co-existing anxiety (confirmed by recognized diagnostic criteria were used in this analysis. Childhood lung function measures were treated or validated measurement scale) were identified for inclusion. Data were ex- as quartiles as well as continuous variables. Associations between childhood tracted by two independent review authors with meta-analyses of outcomes lung function and asthma/COPD/ACOS were examined using multinomial re- performed using the random-effect model using Review Manager Version 5.3. gression. The final multinomial model was adjusted for childhood socio-eco- Results: A total of 943 citations resulted in seven included studies (four nomic status, childhood asthma, childhood lung infection and maternal pharmacological and three psychological). Meta-analysis of all seven re- smoking. vealed significant reductions to anxiety in the treatment arm (mean difference Results: À2.92; 95%CI À5.22 to À0.63; p = 0.01) with the psychological studies producing greater treatment efficacy (p = 0.03; 319 subjects) over pharmacologi- COPD cal (p = 0.22; 59 subjects) within sub-group analysis. A trend towards Current asthma ACOSOR onlyOR significant in favour of the intervention was found for the physical composite Lung function at 7 years only OR (95%CI) (95%CI) (95%CI) of quality of life measured by St George’s Respiratory Questionnaire (standardized mean difference À0.36; 95%CI À0.74 to 0.02; p = 0.06; three stud- Lowest quartile of 1.09 (0.75; 1.58) 3.03 1.20 (0.58; ies); however, no evidence of any effect was found for exercise capacity or FEV1% predicted vs rest (1.72; 2.46) FEV1. 5.33) Conclusions: Psychological therapies appear to be more effective than pharmacological interventions to reduce anxiety in COPD patients. However, Lowest quartile of FEV1/ 1.17 (0.80; 1.75) 6.80 (3.7; 3.0 (1.60; poor methodological quality and small sample size of studies investigating FVC % predicted vs rest 12.3) 5.72) pharmacotherapy may be contributing to this discrepancy. Methodologically, Lowest quartile of FVC% 0.98 (0.68; 1.41) 1.04 (0.56; 0.68 (0.31; rigorous trials of pharmacotherapy are required. predicted vs rest 1.95) 1.51) Grant Support: Nil.

Lowest quartile of FEV1 and FEV1/FVC ratio in childhood was associated with COPD and ACOS (but not asthma only) in middle-age. Results were consistent when childhood lung function measures were analysed as continuous variables.

Conclusions: These data highlight that lung function deficits in early life have long-term consequences for developing COPD and ACOS. Further research is needed to better understand these associations and develop possible interventions for children with impaired lung function. Key words: asthma–chronic obstructive pulmonary overlap syndrome, childhood lung function, middle age. Grant Support: National Health and Medical Research Council of Austra- lia, Clifford Craig Medical Research Trust of Tasmania; Victorian, Queensland & Tasmanian Asthma Foundations. Declaration of Interest Statement: There is no conflict of interest.

TO 084 Cystic Fibrosis Oral Presentations

DYSREGULATED INNATE IMMUNE RESPONSE PATHWAYS IN CHILDREN WITH CYSTIC FIBROSIS FOLLOWING HUMAN RHINOVIRUS INFECTION TO 083 LING K1,SEFERALIA2,GILLE2, GARRATT L1,SUTANTOE1,3,MONT- GOMERY S1, STARCEVICH-KICIC E1, LANNIGAN F4,LOOIK1, IOSIFIDIS NEUTROPHIL ELASTASE ACTIVITY IN EARLY CYSTIC T1,3,5, MARTINOVICH K1,SHAWN1,HANCOCKR2,TURVEYS2,KICIC FIBROSIS PRIOR TO, DURING AND POST PSEUDOMONAS A1,3,5,6,STICKS1,3,5,6 INFECTION 1Telethon Kids Institute, 2University of British Columbia, 3University of West- ern Australia, 4Notra Dame University, 5Centre for Cell Therapy and Regener- 1 1,2,3,4 5,6,7 1,2,3,4 6 7 ’ GARRATT L ,KICICA , RANGANATHAN S , STICK S ,ONBE- ative Medicine, Princess Margaret Hospital, Royal Children s Hospital HALF OF AREST CF1,4,5,6,7 Melbourne 1Telethon Kids Institute, The University of Western Australia, 2School of Pae- diatrics and Child Health, The University of Western Australia, 3Centre for Cell Introduction/Aim: Based from previous observation of dysregulated in- Therapy and Regenerative Medicine, The University of Western Australia, nate immune responses to human rhinovirus 1b (HRV1b) in children with 4Department of Respiratory Medicine, Princess Margaret Hospital for Chil- CF, we aimed to further characterize active pro-inflammatory epithelial net- dren, 5Department of Respiratory Medicine, Royal Children’sHospital,6Mur- works following infection. doch Childrens Research Institute, Royal Children’s Hospital, 7Department Methods: Primary airway epithelial cells (pAEC) were obtained from nine of Paediatrics, University of Melbourne children with CF (median age 4.2 years) when attending their annual bronchoscopy. Healthy pAEC were obtained from children (median age 4.9 years) Introduction/Aim: Early acquisition of Pseudomonas aeruginosa (Psa)by underwent elective surgery for non-respiratory related conditions. Monolayer children with cystic fibrosis (CF) is associated with worse prognosis. Neutro- pAEC were established and infected with HRV1b. Cells were collected at se- phil elastase (NE) activity is also abnormally present in CF airways. We exam- lected times over a 24-h period. RNA was extracted and gene expressions ined NE activity before, during and after Psa infection, to investigate whether quantified by RNA-seq. Sequencing reads were aligned to hg19 reference ge- Psa eradication also successfully reduced NE activity and inflammation. nome using Tophat2, organized using SAMtools and counted using HTseq. Methods: Bronchoalveolar lavage fluid (BALf) from children with CF was Differential expression was assessed using DESeq2. HRV1b was quantified obtained through the AREST CF longitudinal cohort study in Perth and Mel- by aligning unmapped reads to Rhinovirus A genome using Bowtie2. Finally, bourne. Microbiology was assessed using standard qualitative culture tech- pathway analysis was performed using Sigora. niques. Children positive for Psa underwent a program-specific eradication Results: Significant change in gene expression was only detected at 24 h regimen. Additional BALf was collected 3 months after initial isolation to con- timepoint. Here, 513 genes were differentially expressed in CF pAEC follow- < ≥ firm eradication. All BALf were assessed for inflammation including leukocyte ing HRV1b infection with FDR correct p-values 0.05 and fold changes 2. Vi- counts, IL-8 and NE activity. ral copy numbers detected in pAEC peaked at 8 h post-infection and remained Results: Eighty-one episodes of Psa infection in 74 children (median age the same at 24 h post-infection with similar levels detected in both CF and 3.19 years; range 0.27–6.63) were assessed; six children featured multiple healthy pAEC. The most differently expressed genes were associated with vi- α β γ separate episodes. Free NE activity was detected in 46 (56.79%) at time of ralresponsepathwayssuchasIFN / signalling, IFN signalling and RIGI/ α β Psa. Mean NE activity (137.80 nM ±385.60) was significantly higher than both MDA5 mediated induction of IFN / pathways. An exaggerated response β λ λ λ the prior annual BALf (35.31 nM ±84.49, p = 0.0444), and peers who never was observed via upregulation of IFN 1, IFN 1, IFN 2, IFN 3, RIGI and cultured Psa (33.58 nM ±86.93, p < 0.0001). After eradication therapy, Psa MDA5 genes in children with CF compared to healthy. was not detected in 69 cases (87.34%). Although prevalence of free NE Conclusions: Infection of CF pAEC with HRV1b resulted in upregulation of was lower post-eradication (n = 26, 35.14%), mean activity was not signifi- genes involved in classic viral response pathways compared to healthy pAEC. cantly different (124.30 nM ±614.70, p = 0.0645). On an individual basis, NE Results support the view of dysregulated innate immune responses to viral in- activity was still detected in 19 cases despite successful Psa eradication. At fection in CF. Targeting the inflammatory pathway could potentially identify following annual assessment (n = 67), both prevalence (n = 23, 34.33%) and novel drug targets to prevent onset of lung disease in CF. mean activity (60.60 nM ±181.10, p = 0.0334) remained significantly lower Grant Support: NHMRC (#1069101). than Psa infection. No significant changes were observed in IL-8 or neutrophil Declaration of interest: No conflicts of interest to declare. cell count. Conclusions: Prevalence and activity of NE were associated with Psa infection that was not always resolved following eradication. The treatment of residual protease activity during Psa eradication regimens should also be investigated for potential to prevent additional lung damage. Grant Support: NHMRC and USCFFT.

TO 085 TO 086

PSEUDOMONAS AERUGINOSA POPULATION FLUCTUATION ASSOCIATION OF GLUTATHIONE-S-TRANSFERASE GENE IN CYSTIC FIBROSIS PULMONARY EXACERBATIONS—A VARIANTS AND EARLY INFECTION IN YOUNG CHILDREN BATTLE OF THE STRAINS? WITH CYSTIC FIBROSIS

TAI A1,KIDDT1,5, BUCKLEY C1,RAMSAYK1,3,GRIMWOODK1,6,BELL HUTCHIN A1,TURKOVICL1,STICKS1,2, LIANG I1,3,FRANKSK3,KHOO S1,2,4,WHILEYD1 S3, PADROS-GOOSENS M1,BERRYL1 1Queensland Children’s Medical Research Institute, The Prince Charles 1Telethon Kids Institute, 2Princess Margaret Hospital, 3Department of Hospital, 2Adult Cystic Fibrosis Centre, Department of Thoracic Medicine, Paedriatics, University of Western Australia The Prince Charles Hospital, 3School of Medicine, The University of Queens- 4 5 land, QIMR Berghofer Medical Research Institute, Cenre for Infection and Introduction/aim: Cystic fibrosis (CF) is characterized by chronic respira- 6 Immunity, Queen’s University Belfast, Griffith Health Institute, Griffith Univer- tory infection, inflammation and oxidative stress that leads to irreversable sity and Gold Coast University Hospital structural lung disease. Disease severity is highly variable. Other factors, such as other genes and environmental exposures (i.e. exposure to tobacco smoke Introduction/Aim: P. aeruginosa airway populations undergo intra-strain (TS)), may modify the severity of CF disease. Genetic modifiers may exist in diversification during chronic adaptation to the CF airways. Changes within the glutathione (GSH) antioxidant pathway as it mediates oxidative stress, P. aeruginosa airway populations during intravenous (i.v.) antibiotics for CF and GSH is reduced in CF airways. This study investigates whether glutathi- pulmonary exacerbations are unclear. We aim to characterize P. aeruginosa one-s-transferase (GST) variants in GSTT1, GSTM1 and GSTP1 are associ- population density, diversity and dynamics during i.v. antibiotics for CF ated with early infection and if that association is modified by exposure to TS. exacerbations. Methods: Data for 161 children from the AREST CF cohort aged 0–6years Methods: Twelve consecutive CF patients hospitalized for exacerbation was available across multiple visits (n = 873). Infection was defined as pres- were recruited. Sputum samples were collected on day 1, 7, 14, discharge ence of pathogens detected in broncheoleavar fluid (BALF). Infection out- and follow-up. Forty-eight P. aeruginosa isolates were randomly selected from comes were analysed using logistic regression models. In utero TS each sample and strain-typed by AUST-02 PCR and MLST. Detailed pheno- exposure was also investigated as a possible effect modifier of association be- typic and genotypic characterization of P. aeruginosa isolates (n = 480) from tween GST variants and infection. Pro-inflammatory pathogens were defined two patients was performed. as the presence of any: Staphylococcus aureus, Haemophilus influenza, As- Results: A total of 2448 isolates were analysed from 51 sputa collected pergillus spp or Pseudomonas aeruginosa. during 13 exacerbation episodes in 12 patients. Strain-types obtained in Results: The odds of infection of any density were significantly increased in 2326 /2448 P. aeruginosa isolates (95%) comprised AUST-02 (55.5%), children that inherited a null GSTT1 genotype and were exposed to in utero AUST-06 (36.1%), AUST-07 (4.4%), AUST-11 (3.8%), AUST-01 (0.1%) and TS compared to those that were not exposed and inherited a functional unique strains (0.1%). Seven out of 12 patients were infected with a single GSTT1 genotype OR = 4.96 95% CI (3.26, 6.74), p < 0.001. The association strain, and 5/12 patients had AUST-02 and AUST-06 co-infection. Transient was even stronger with infection with pro-inflammatory pathogens OR = 9.21 reduction in P. aeruginosa density occurred after the first week of antibiotics (6.24, 13.59) p < 0.001. We also found increased ORs for both any infection (p = 0.06), followed by significant resurgence to pre-treatment levels after and pro-inflammatory infection, in children with GSTP1 A105G AG or GG 2weeks(p = 0.05). Significant reduction in the relative proportion of AUST- and were TS exposed compared to AA/TS unexposed group (p < 0.001 for 02 (mean difference: 23%; 95%CI: 6–40%; p-value: 0.02) was associated with both). an increase in AUST-06 (mean difference: 21%; 95%CI: 5–%; p-value: 0.02) Conclusions: GSTT1 and GSTP1 A105G variants may impair glutathione between the start and end of antibiotics in those with co-infection. Extensive pathway antioxidant functions and, in combination with an increased within-patient P. aeruginosa population diversity was observed. Temporal se- eviromental toxin load from TS, result in increased susceptibility to early infec- lection of β-lactam resistant, tobramycin susceptible and non-pyocyanin tion of children with CF. overproducing phenotypes was observed during antibiotics. Grant Support: UWA research development award, NHMRC and USCF. Conclusions: Antibiotic treatment was associated with transient changes in P. aeruginosa density. P. aeruginosa airway population demonstrated extensive diversity. In vivo competition between co-existing P. aeruginosa strains and intra-strain sublineages was observed during antibiotics. Clinical correlation between P. aeruginosa sublineages selection during antibiotics and clinical response to antibiotic treatment warrants further investigation. Grant Support:NHMRC Dental and Medical Post-graduate Scholarship, Cystic Fibrosis Australia - Postgraduate-Scholarship,TPCH Research Foun- dation Experienced Researcher Grant,QCMRI Program Grant andOHMR Health Research Fellowship and Early Career Fellowship Grant. Declaration of Interest Statement: All authors have no competing interest to declare.

TO 087 TO 088

PROVISION OF TELEHEALTH IMPROVES CLINIC ARE STAPHYLOCOCCUS AUREUS INFECTIONS CAUSALLY ATTENDANCE TO MEET RECOMMENDED STANDARDS OF RELATED TO MORE RAPID DISEASE PROGRESSION IN CARE IN ADULTS WITH CF LIVING IN RURAL AND REMOTE CHILDRENWITHCYSTICFIBROSIS? WESTERN AUSTRALIA CAUDRI D1,TURKOVICL1,NGJ1, DE KLERK N1, ROSENOW T1,HALL WOOD J1,2,3,HILLK1,3,CECINSN2, MULRENNAN S3,4,MOREYS3,4, G1,2, RANGANATHAN S4,5,6, STICK S1,2 JENKINS S1,2,3 1Telethon Kids Institute, University of Western Australia, Subiaco, Australia, 1School of Physiotherapy and Exercise Science, Faculty of Health Science, 2Department of Respiratory Medicine, Princess Margaret Hospital for Curtin University, WA, Australia, 2Physiotherapy Department, Sir Charles Children, Subiaco, Australia, 3Department of Pediatrics/Respiratory Medicine, Gairdner Hospital, WA, Australia, 3Institute for Respiratory Health, WA, Erasmus University, Rotterdam, The Netherlands, 4Murdoch Childrens Re- Australia, 4Department of Respiratory Medicine, Sir Charles Gairdner search Institute, Parkville, Australia, 5Department of Respiratory Medicine, Hospital, WA, Australia Royal Children’s Hospital, Parkville, Australia, 6Department of Paediatrics, University of Melbourne, Parkville, Australia Introduction/Aim: A significant proportion (15%) of the 190 adults with CF who attend the Western Australian (WA) state adult CF centre live in rural and Introduction/Aim: Cystic fibrosis (CF) is characterized by pulmonary in- remote areas. Rural patients are often unable to access specialist care regu- flammation and infection, leading to structural lung disease. We hypothesized larly due to the financial and travel burden associated with the long distances that Staphylococcus aureus (SA) infections are not only a marker of underly- to the centre. We aimed to improve access by offering care via telehealth to ing CF disease severity but also an important causal factor for more rapid dis- those living in rural and remote areas and to evaluate the impact on health ease progression. outcomes. Methods: In the Australian Respiratory Early Surveillance Team for Cystic Methods: Participants were offered clinics via telehealth from their local Fibrosis (AREST CF) study, children diagnosed with cystic fibrosis at birth un- hospital over a 12-month period. Number of clinic visits, hospital admissions dergo an annual bronchoscopy, broncho-alveolar lavage (BAL) and ultra low- and courses of intravenous antibiotics (IVAB) were collected for the 12-month dose chest computed tomography (CT) up to the age of 6 years. Spirometry is period preceding recruitment and at the end of the intervention period. Health- attempted on a 3-monthly basis from the age of 5 years. We examined the as- related quality of life (HRQoL) and spirometry were collected at each visit. sociation between first SA acquisition (age 0–3 years) and CT scan and spi- Results: Twenty-three adults with CF (14 female, aged [mean ± SD] 31 rometry outcomes at the age of 5–7 years. In order to account for ± 10 years, FEV1 60 ± 20 %predicted) who lived in rural and remote WA were confounding by underlying disease severity, associations were adjusted for recruited for this study, with 20 participants completing the intervention period. previously existing structural abnormalities, clinical prognostic markers and in- There was no change in HRQoL or spirometry. flammatory markers in BAL samples. Table: Healthcare utilization (data are median [min–max] for all measures) Results: Data on SA and CT follow-up were available in 111 children, with additional complete data on all defined confounders available in 77 children. Pre telehealth During telehealth First acquisition of SA at the age 3 (n = 14/77, 18%) was significantly associated with increased bronchiectasis score at the age of 5–6(meandifference n Per participant n Per participant p in bronchiectasis score 3.61 points, 95%-confidence interval (95%-CI): 1.53–5.71, p = 0.001). This association remained significant after adjustment – – for markers of disease severity at baseline (mean difference in bronchiectasis CF clinics 40 2 (0 4) 96 5 (2 8) 0.001 – – – score 2.56, 95%-CI: 0.59 4.53, p = 0.012). The association could not be ex- IVAB courses 13 0 (0 3) 24 1 (0 4) 0.01 plained by later acquisition of Pseudomonas aeruginosa. SA infections were – – Admissions 7 0 (0 2) 18 1 (0 3) 0.02 significantly associated with a reduced FEV1-%-predicted at age 5–7 years, but this association did not remain significant after adjustment for baseline markers of disease severity. Conclusion: Our analyses offer support for the hypothesis that SA infections are a causal risk factor for the more rapid development of structural lung Conclusions: In adults with CF living in rural and remote WA, this damage in children with cystic fibrosis. telehealth intervention improved outpatient clinic attendance to meet recom- Key words: bronchiectasis, cystic fibrosis, infection, Staph aureus mended standards of care (≥4 clinic visits per year). The short-term increase Nomination for Janet Elder International Travel Award in IVAB use and hospital admissions likely reflects the improved surveillance Grant Support: Research Fellowship by the Rothwell family, Ter Meulen of participants and detection of exacerbations. This may reduce the long-term Grant of the Royal Netherlands Academy of Arts and Sciences, Research Fel- rate of decline in lung function in this population. lowship Sophia 2014 of the Sophia Childrens’ Hospital Fund. Grant Support: Institute for Respiratory Health Glenn Brown Memorial Grant.

TO 090 OLIV 1 Oral Presentations

SERUM MMP7 IS INCREASED IN PATIENTS WITH PROGRESSIVE IDIOPATHIC PULMONARY FIBROSIS TO 089 JAFFAR J1,2, SYMONS K1, GOH N1,O’HEHIR R1,2,SCHULIGAM3, STEWART A3,WESTALLG1,2,GLASPOLEI1 1Department of Allergy, Immunology and Respiratory Medicine, The Alfred INTERIM ANALYSIS OF NINTEDANIB IN AN OPEN-LABEL Hospital, Melbourne, Australia, 2Department of Immunology and Pathology, EXTENSION OF THE INPULSIS® TRIALS (INPULSIS®-ON) Monash University, Melbourne, Australia, 3Department of Pharmacology and Therapeutics, University of Melbourne, Australia CORTE T1,CRESTANIB2,OGURAT3,PELLINGK4, COECK C5, QUARESMA M6, KREUTER M7,KAYEM8 Introduction/Aim: Biomarkers that accurately reflect disease progression 1University of Sydney and Department of Respiratory Medicine, Royal Prince are needed in fibrotic lung disease. In patients with idiopathic pulmonary fibro- Alfred Hospital, 2Hôpital Bichat, Pneumologie, Paris, France, 3Department of sis (IPF), matrix metalloproteinase levels (MMP)-7 are increased in broncho- Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, alveolar lavage fluid and elevated levels of proMMP-7 are excessively Yokohama, Kanagawa, Japan, 4Boehringer Ingelheim Ltd., Bracknell, UK, produced by hyperplastic alveolar and metaplastic bronchiolar epithelial cells. 5SCS Boehringer Ingelheim Comm.V., Brussels, Belgium, 6Boehringer MMP-7 has been identified as a potential biomarker in IPF. However, its utility Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany, 7Depart- in other interstitial lung diseases (ILD) has not been evaluated. ment of Pneumology, Thoraxklinik, University of Heidelberg, and Translational Methods: Sixty-six patients attending The Alfred ILD clinic had serum col- Lung Research Center Heidelberg, German Center for Lung Research lected and were followed for disease progression. Diagnoses of ILD were de- Germany, 8Minnesota Lung Center, Ltd., Minneapolis, Minnesota, USA termined by multidisciplinary review. Active disease was defined as having either ≥10% decline in absolute FVC, undergoing transplantation or death Introduction/Aim: The INPULSIS® trials assessed the efficacy and safety within 12 months of the date of blood sampling. Expression of MMP7 in lung of nintedanib 150 mg twice daily in patients with idiopathic pulmonary fibrosis. tissue was measured in both IPF (n = 5) and healthy lungs (n =5). Results: Serum levels of MMP7 in all ILD patients were increased com- Nintedanib significantly reduced the annual rate of decline in FVC compared < with placebo in both trials. Patients who completed the 52-week treatment pe- pared to healthy controls (n =7; p 0.001). In patients with IPF, serum riod and follow-up visit 4 weeks later (n = 807) could receive open-label MMP7 levels were significantly increased in those who had active disease nintedanib in an extension trial. The aim of the present study was to assess (n = 21) compared to those who remained stable (n =11; p = 0.039). There the long-term efficacy and safety of nintedanib. was no difference in serum MMP7 between the non-IPF ILD patients, regard- Methods: Patients treated with placebo in the INPULSIS® trials initiated less of disease activity. In patients with IPF, but not in those with other ILD, se- treatment with nintedanib in the extension; patients treated with nintedanib rum MMP7 levels were inversely correlated with percent predicted DLco continued to receive nintedanib. (R = 0.6, p = 0.001). Serum MMP7 levels showed no detectable correlation Results: A total of 734 patients were treated in the extension trial (430 con- with percent predicted FEV1 or FVC in any of the ILD groups. MMP7 levels tinuing nintedanib and 304 initiating nintedanib). Baseline characteristics were were localized to alveolar epithelial cells in the distal parenchyma and were in- similar between groups. For patients initiating nintedanib, mean (SD) duration creased in patients with IPF compared to healthy controls. of exposure was 16.0 (7.3) months; for patients continuing nintedanib, mean Conclusions: Serum MMP7 levels may be a useful biomarker of active (SD) duration of exposure in the extension was 17.2 (6.6) months, resulting disease in patients with IPF. Longitudinal serum measurements are needed in a mean (SD) duration of exposure across the parent and extension trial of to investigate the stability of serum MMP7 in patients with ILD/IPF. 29.2 (6.6) months. Among all patients treated in the extension, mean change Grant Support: Nil. in FVC from the start of the extension to week 48 was À87 mL (À1.95% FVC predicted). In total, 92.8% of patients continuing nintedanib and 96.7% initiated on nintedanib had ≥1 adverse event during the extension. The most frequent adverse event was diarrhoea, reported in 63.3% of patients continuing nintedanib and 64.1% of patients initiated on nintedanib. Conclusion: An interim analysis of data from the INPULSIS®-ON extension trial confirmed the efficacy and safety observed in the INPULSIS® trials. Grant Support: The INPULSIS® trials were funded by Boehringer Ingelheim. Declaration of interest statement: Tamera Corte has received unrestricted educational grants from Intermune and Boehringer Ingelheim, served on advisory boards for Roche, AstraZeneca and Boehringer Ingelheim and received research funding from Roche, Actelion, Bayer and Gilead.

TO 091 TO 092

QUALITY OF LIFE OF PATIENTS WITH IDIOPATHIC BASELINE PULMONARY FUNCTION TEST PREDICTS PULMONARY FIBROSIS (IPF)—WHAT CAN THE AUSTRALIAN SURVIVAL: ANALYSIS FROM THE AUSTRALIAN IPF IPF REGISTRY TELL US? REGISTRY

GLASPOLE I1,2,GOHN1, HOPKINS P3,MOODLEYY4, REYNOLDS P5, JO H1,2,GLASPOLEI3,4, GOH N3,HOPKINSP5, MOODLEY Y6, WALTERS E6, ZAPPALA C7, ALLAN H8,CHAPMANS5,COOPERW9, REYNOLDS P7, WALTERS H8, ZAPPALA C9, ALLAN H10, CHAPMAN S7, ELLIS S10,MAHARA9,CHAPLINH8,HENSONR8, MACANSH S8, COOPER W1, ELLIS S3, GRAINGE C11,KEIRG12,MAHARA1,CORTET1,2 RICHARDS S8, SMITH S8,SYMONSK8,PAULE2,CORTET 1Royal Prince Alfred Hospital, Sydney, NSW, Australia, 2Univeristy of Sydney, 1The Alfred Hospital, Melbourne, VIC, Australia, 2Monash University, Sydney, NSW, Australia, 3The Alfred Hospital, Melbourne, VIC, Australia, Melbourne, VIC, Australia, 3The Prince Charles Hospital, Brisbane, QLD, 4Monash University, Melbourne, VIC, Australia, 5The Prince Charles Hospital, Australia, 4Fiona Stanley Hospital, Perth, WA, Australia, 5Royal Adelaide Brisbane, QLD, Australia, 6Royal Perth Hospital, Perth, WA, Australia, 7Royal Hospital, Adelaide, SA, Australia, 6CRE, University of Tasmania, Hobart, Adelaide Hospital, Adelaide, SA, Australia, 8University of Tasmania, Hobart, TAS, Australia, 7Royal Brisbane and Women’s Hospital, Brisbane, QLD, TAS, Australia, 9Royal Brisbane & Women’s Hospital, Brisbane, QLD, Austra- Australia, 8Lung Foundation Australia, Brisbane, QLD, Australia, 9Royal lia, 10Lung Foundation Australia, Brisbane, QLD, Australia Prince Alfred Hospital, Sydney, NSW, Australia Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal Introduction: IPF is a progressive, fibrosing lung disease causing dimin- lung disease characterized by progressive loss of lung function. The natural ished health-related quality of life (HRQoL). history for an individual with IPF is variable. We aimed to identify baseline Aim: We sort to determine the principal determinants of HRQoL in IPF. physiological variables predictive of disease progression and/or mortality in Methods: Data from the Australian IPF Registry were analysed for demo- Australian IPF patients. graphic features, comorbidities, St George Respiratory Questionnaire Methods: The Australian IPF Registry (AIPFR) recruits IPF patients across (SGRQ), Hospital Anxiety and Depression (HAD-A and D) scale, UCSD Australia. State-based co-ordinators collate patient questionnaires, physiolog- Shortness of Breath Questionnaire (UCSD), cough, oxygen use, spirometry, ical data and vital status every 6 months, providing a real world, longitudinal DLCO and 6 MWT parameters. Linear regression analysis was performed to cohort. Disease progression is defined as a sustained relative fall in identify predictors of HRQoL. FVC > 10% or DLCO > 15% from baseline. The predictive capacity of base- Results: Data from 516 patients were available (347 male; mean age 71.3 line variables for mortality and disease progression was assessed by Cox sur- ± 8.6 years). Mean FVC 81.3 ± 22.5%pr, DLco 46.7 ± 17.4%pr, 6 MWD 434 vival analysis. ± 135 m, resting SpO2 95.1 ± 3.3%, end-exercise SpO2 84.8 ± 6.9%. SGRQ Results: There were 625 participants (68.8% male; mean age 71.7 score: symptom 47.2 ± 23.5; activity 61.9 ± 23.9; impact 37.3 ± 22.9; total + 9.2 years) enrolled in the AIPFR in September 2015. Most had a history of 46.6 ± 20.9. Symptom scores: UCSD median 38 (17–67); HAD-A score 4 smoking (71.2%), and a significant number reported co-morbidities including (2–7), 20.3% > 8, HAD-D score 4 (2–7), 17.7% > 8; cough presence 88.5%; COPD (30.1%) and GORD (35.5%). Most participants had mild to moderate cough severity (visual analogue scale 0–100 mm): 40.3 ± 25.8. Significant as- impairment with FVC 80.6 + 21.4% and DLCO 48.6 + 16.7%. sociations on univariate analysis with HRQoL included: GAP index, smoking, On univariate Cox regression, the following variables predicted mortality: age, cardiorespiratory comorbidity, oxygen therapy, UCSDSOBQ, HAD-A, HAD-D, BMI, smoking status, FVC%, DLco%, composite physiological index (CPI) cough presence and severity, FEV1, FVC, DLCO, 6 MWT distance, baseline and 6-min walk distance. On multivariate analysis, FVC (HR 0.09; and end test oxygen saturation and end 6 MWT dyspnea score. Multivariate p < 0.0001; 95% CI 0.02–0.34), DLco% (HR 0.01; p < 0.0001; 95% CI analysis of 109 subjects with complete data demonstrated independent asso- 0.001–0.07), age (HR 1.04; p = 0.001; 95% CI 1.02–1.08) and BMI (HR ciation between SGRQ and UCSDSOBQ (R2 =0.76,p < 0.0001), cough se- 0.95; p = 0.04; 95% CI 0.90–0.998) independently predicted mortality. Pro- verity (R2 = 0.07, p < 0.0001), HAD-D (R2 = 0.02, p = 0.003) and age gression free survival was independently associated with FVC and DLco, (R2 =0.01,p = 0.015). but not with age. Patients with mild disease (FVC > 80%) had a decreased Conclusions: Cough, dyspnoea and depression are major determinants risk of death or progression (HR 1.9; p < 0.0001; 95% CI 1.47–2.48). of HRQoL in IPF. Their treatment may improve HRQoL and should be a focus Conclusions: Mortality and disease progression are associated with lower of future clinical trials. baseline FVC and DLco in Australian IPF patients. While older age was a sig- Grant Support: The Australian IPF Registry is funded by a philanthropic nificant predictor of mortality, it was not significant for progression free survival family and unrestricted educational grants from foundation partners, Roche suggesting that older participants may die from causes other than IPF. and Boehringer-Ingelheim and project partner Gilead Sciences. Key words: disease progression, idiopathic pulmonary fibrosis, physiology, survival Grant Support: H Jo has received grant funding from the Lung Foundation Australia. The Australian IPF Registry is funded by a philanthropic family and an unrestricted educational grant from foundation partners InterMune and Boehringer Ingelheim and project partners Bayer Australia and Gilead Sci- ences Inc.

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RITUXIMAB MAY BE AN EFFECTIVE RESCUE THERAPY IN ANXIETY AND DEPRESSION IN IDIOPATHIC PULMONARY CONNECTIVE-TISSUE DISEASE-ASSOCIATED INTERSTITIAL FIBROSIS LUNG DISEASE GLASPOLE I1,2,WATSONA3, MACANSH S4,CHAPMANS5,COOPERW6, TROY L1,2,KEIRG3,JOH1,2, LAU E1,2,TAYLORN1, WEBSTER S1, ALLAN H4, ELLIS S1, GOH N1,3, GRAINGE C7, HOPKINS P8,KEIRG9, TORZILLO P1,2,CORTEP1,CORTET1,2 MAHAR A6, REYNOLDS P5,WALTERSE10,ZAPPALAC11,MCCORMACK 1Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, S6,MOODLEYY12,CORTET6,HOLLANDA Camperdown, NSW, Australia, 2Sydney Medical School, University of Syd- 1Alfred Hospital, 2Monash University, Melbourne,VIC, Australia., 3Institute of ney, Sydney, NSW, Australia, 3Department of Respiratory Medicine Princess Breathing and Sleep, Austin Health, Melbourne, VIC, Australia, 4Lung Foun- Alexandria Hospital, Brisbane, Qld, Australia dation Australia, Brisbane, QLD, Australia, 5Royal Adelaide Hospital, Introduction/Aim: Connective-tissue disease-associated interstitial lung dis- Adelaide, SA, Australia, 6Royal Prince Alfred Hospital, Sydney, NSW, Austra- ease (CTD-ILD) may be progressive, despite treatment with standard immu- lia, 7John Hunter Hospital, Newcastle, NSW, Australia, 8The Prince Charles nosuppressive therapy. Observational studies have shown rituximab (an Hospital, Brisbane, QLD, Australia, 9Princess Alexandra Hospital, Brisbane, anti-CD20 monoclonal antibody) to be a beneficial salvage therapy in these QLD, Australia, 10CRE, School of Medicine UTas, Hobart, TAS, Australia, diseases. We aimed to confirm these observations in an Australian cohort of 11Royal Brisbane & Women’s Hospital, Brisbane, QLD, Australia, 12Fiona CTD-ILD patients. Stanley Hospital, Perth, WA, Australia, 13School of Physiotherapy, Latrobe Methods: A retrospective analysis of CTD-ILD patients receiving rituximab University, Melbourne, VIC, Australia, 14Department of Physiotherapy, The (given as two intravenous doses of 1 gram, two weeks apart), at two Australian Alfred Hospital, Melbourne, VIC, Australia tertiary interstitial lung disease centres was performed. Lung function and six- minute walk tests (6MWT) were measured at 3-6 monthly intervals before and Introduction: Mood disturbance commonly effects people with IPF. No after therapy studies evaluating persistent depression beyond 6 months exist, and there Results: Eleven patients (7 females, mean age 61.7 ± 10.5yrs) were studied. are no longitudinal studies evaluating persistent anxiety in IPF. Diagnoses included dermatopolymyositis (n=7), scleroderma (n=3) and mixed Aim: Our aim is to determine the frequency and predictors of persistent connective tissue disease (n=1). All patients had progressive lung disease de- anxiety and depression in IPF. spite receiving conventional therapy with corticosteroids (n=10), cyclophos- Methods: Using the Australian IPF Registry (AIPFR), we examined a cohort phamide (n=9), mycophenolate mofetil (n=5), and/or azathioprine (n=2). At with persistent anxiety and depression defined as that present at baseline the time of rituximab therapy, mean FVC was 57.8 ± 16.6% predicted, DLCO and 12 months follow-up, via the Hospital Anxiety and Depression Scale 38.2 ± 14.4% and 6MWD 425 ± 116.0m. In the 6-12 months preceding ther- (HAD-A & D). Univariate and multivariate logistic regression analysis was per- apy, the median relative fall in FVC was -11.0% (range -31.7 to 17.6%), with formed examining associations with demographic features, comorbidities, median relative decline in DLCO of -19.1% (-55.4 to 24.5%). At 3-months UCSD shortness of breath questionnaire (UCSD), cough severity (visual ana- post-rituximab, median FVC had increased relative to nadir by 3.2%, (-3.0 to logue scale 0–100 mm), oxygen use, hospitalization, spirometry, DLCO, 14.3%, p=0.04), median DLCO had increased by 6.0% (-17.4 to 22.8%, 6 MWT and survival. p=0.04). In 4 subjects with 6-12 month follow-up data, median FVC had in- Results: One hundred two of 435 participants in the AIPFR had completed creased by 7.7% (-5.6 to 21.0%, ns), and DLCO had improved by 5.5%, (- baseline and 12 month follow up HAD-A & D questionnaires: 66 male; mean 18.3 to 61.4%, ns). Two patients died during the median follow-up period of (±SD) age 69.6 ± 6.9 years. Twenty subjects (21%) had persistent anxiety, 12 months, (3 to 53 months). and 14 subjects (14%) had persistent depression. Univariate analysis demon- Conclusion: In an Australian cohort of CTD-ILD patients with progressive dis- strated persistent anxiety was associated with the degree of baseline dys- ease, Rituximab achieved stability or improvement in FVC and DLCO at 3- pnoea (p = 0.008), a trend for association with baseline cough severity months. Further follow-up will help to determine duration of benefit. (p = 0.07) and oxygen use (p = 0.07). Multivariate analysis demonstrated oxy- Randomised controlled trials are needed to definitively establish the role for ri- gen use as the only independent predictor of persistent anxiety. Worsening tuximab in these diseases. anxiety was associated with worsening cough severity (p = 0.015). Univariate analysis demonstrated persistent depression was associated with the degree of baseline dyspnoea (p = 0.004), cough at baseline (p = 0.003) and had a trend for association with younger age (p = 0.06) and worsening dyspnoea (p = 0.07). Multivariate analysis showed that persistent depression was independently predicted by cough severity (p = 0.015) and confirmed a trend for association with younger age (p = 0.066). Worsening depression was associated with worsening dyspnea (p = 0.047). Conclusions: These data confirm the strong link between mood disturbance and symptom severity. Further research is needed to explore the direc- tion of causality of this link so as to optimize palliative approaches. Grant Support:

TO 096 Interventional Pulmonary/Bronchology 1 Oral Presentations OUTCOMES OF AN INITIATIVE TO IMPROVE INPATIENT SAFETY OF THORACOSTOMY TUBE INSERTION

1,2 1 1 TO 095 SANTOS C ,GUPTAS , WILLIAMSON J 1Liverpool Hospital, 2Campbelltown Hospital

Background: Tube thoracostomy is a common hospital procedure with CLINICAL OUTCOMES OF MESOTHELIOMA VS NON- several documented risks, which include life-threatening complications such MESOTHELIOMA PATIENTS TREATED WITH INDWELLING as pneumothorax visceral damage, tube displacement and tube blockage. PLEURAL CATHETERS (IPCS) Methods: In a major metropolitan tertiary hospital, we performed an audit of outcomes in inpatients undergoing small bore intercostal catheter insertion 1,2 2 1 1,2,3 1,2,3 AZZOPARDI M ,RANDAZZOS, RASHID R ,THOMASR , LEE Y (ICC) over a 2-year period. This was followed by a comprehensive quality im- 1 Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia., provement initiative involving limiting the number of procedural clinicians, 2 School of Medicine and Pharmacology, University of Western Australia, training in thoracic ultrasound, using a dedicated pleural procedure room, 3 Perth, Australia, Institute of Respiratory Health, Perth, Australia training nursing staff in assisting ICC insertion and ensuring senior supervision when junior medical officers were inserting ICC’s. Results over the next IPC is increasingly used in malignant pleural effusion (MPE) management. 2 years were then assessed. Existing literature on IPC described only cohorts with predominantly metasta- Results: Preliminary results are presented in Table 1. Image guidance be- tic pleural cancers. Western Australia has the world’s highest incidence of me- came universal after implementation of the QI initiative. The rate of pneumo- sothelioma, and most (>90%) patients suffer from a MPE. Mesothelioma has thorax requiring intervention fell, and although the rate of radiologically unique biology and disease course, different from metastatic pleural detectable pneumothorax remained, all were documented <1.5 cm in size. carcinomas. Documentation and patient pain control improved. Aim: This study provides the largest cohort of mesothelioma patients treated with IPC to describe their clinical outcomes. Patients with effusions Table I. ICC insertion and complications from metastatic pleural cancers formed the comparison group. Methods: All patients with MPEs treated with IPCs at Sir Charles Gairdner Pre-intervention Post- Hospital between 01-04-2009 and 31-05-2015 were included. Clinical out- Outcome N 102 intervention comes were extracted from hospital records. Results: Of the 183 patients studied, 96 had mesothelioma, most of whom Image guided 24 (23%) 105 (100%) were male (89% vs 45% in non-mesothelioma group; p < 0.001). On the day Clinically signiﬁcant 6(6%) 2(1.9%) of censor (31-05-2015), 70% of mesothelioma patients and 71% of non-mesothelioma patients had died. pneumothorax Mesothelioma patients survived longer following diagnosis of the MPE (me- Chest wall infection 1 (1%) 0 dian 337 vs 146 days in non-mesothelioma group) and after IPC insertion (me- Pain 14 (14%) 4 (4%) dian 216 vs 74 days), both p < 0.0001. IPCs were inserted later in Vosovagal syndrome 1 (1%) 4 (4%) mesothelioma patients following diagnosis of the MPE (median 72 vs 17 days; Insufﬁcient documentation 9 (9%) 1 (1%) p < 0.001). Despite that, mesothelioma patients had IPCs in-situ for longer (median 158 vs 76 days, p < 0.001). IPCs were removed in 47% of mesothelioma patients (vs 40% in non-mesothelioma group). Conclusions: We have documented that a comprehensive quality im- IPC complications were uncommon and generally mild; none fatal. The pat- provement initiative prevents complications, improves patient experience tern of results remained similar when analyses were restricted to those who and documentation when applied to inpatient ICC insertion. died. The mesothelioma group had more catheter tract metastases (9.4% vs 0%; p = 0.004) and pleural infection (14.5% vs 3.5%; p = 0.01). More mesothelioma patients had pleural fluid bacterial colonization (37.5% vs 19.5%; p < 0.01). Conclusions: IPC can be safely used in mesothelioma patients. Mesothe- lioma patients required IPC in-situ for longer. Complications are relatively in- frequent but occurred more commonly in mesothelioma (than non- mesothelioma) patients. Grant Support: WA Cancer & Palliative Care Network; NHMRC Fellow- ships (RT; YCGL).

TO 097 TO 098

IMPROVED FORCED OSCILLATION TECHNIQUE (FOT) A COMPARISON OF HIGH FLOW VERSUS STANDARD LOW PARAMETERS CORRELATE WITH LUNG FUNCTION FLOW NASAL OXYGEN DURING DIAGNOSTIC IMPROVEMENTS IN ENDOSCOPIC LUNG VOLUME BRONCHOSCOPY REDUCTION (ELVR) FOR COPD HERSCH N1,DONG1, HIBBERT M1, MELLISH C2, OTTEY J2,NEWMANJ2, HSU K, FARAH C, WILLIAMSON J, PETERS M, ING A HARRIS B1 Macquarie University Hospital 1Respiratory Department, Royal North Shore Hospital. NSW, Australia, 2Endoscopy Unit, Royal North Shore Hospital, NSW, Australia Introduction: ELVR is an established treatment for selected patients with severe heterogeneous COPD. It has been shown to reduce hyperinflation Introduction/Aim: Up to 20% of bronchoscopic procedures are limited by and gas trapping, with improvements in ventilatory function for at least hypoxia (1). Patient comorbidities, sedation and partial obstruction of the air- 12 months. FOT is an increasingly recognized clinical tool in assessing small way contribute to this risk. High flow nasal oxygen (HFNO) provides a rela- peripheral airway function. The effect of ELVR on FOT has not been reported tively inexpensive, non-invasive form of humidified oxygen with some previously. We report a case series of three patients with severe COPD who pressure support which facilitates better oxygenation in certain patient popula- had ELVR in 2015 and correlate the FOT parameters with RFT, 6 MWD and tions (2, 3). Theoretically, giving PEEP even at low pressures may assist with quality of life scores. reducing airway closure and hypoxia thereby facilitating better inspection of Case details: The three cases aged 75, 65 and 66 underwent ELVR with the bronchial tree. However, there are no large randomized controlled trials bronchial valves to treat the most emphysematous lobe(s). RFT (spirometry, of HNFO in adults undergoing bronchoscopy. Specifically, it is unknown static lung volumes and gas transfer capacity) and FOT parameters (resistance whether HFNO reduces desaturation events during procedures. In this study, and reactance at 5 Hertz (R5 and X5)) were measured pre- and post-ELVR. we investigate whether HFNO will reduce the oxygen desaturation index 6 MWT and SGRQ were also completed. All had 1 month, and two had 3-month (ODI) compared to standard low flow nasal cannulae (LFNC). Furthermore, follow-up data. All had significant improvements in SGRQ scores up to we explore whether there is an additional effect on procedure tolerance. 3 months. The degree of improvements in FOT parameters was more significant Methods: We aim to conduct a randomized trial of 100 patients to either in patients who had improved RFT and 6 MWD. standard LFNC (starting at 4 L/min) or humidified HFNO (starting at 40 L/min and Fi02 0.3) during bronchoscopy. Oximetry will be measured to calculate an ODI. Data including body mass index and comorbidities will be collected. A questionnaire performed 60 min post-procedure will be used to document procedural satisfaction. Results: To date, 12 patients have been enrolled (seven to HFNP and five to NC). Average drug doses used for sedation in the HFNP and LFNC group were no different with 5.1 +/À 2.3 mg and 4.8 +/À 1.3 mg of midazolam (p = 0.7) and 110 +/À 40 mcg and 105 +/27 mcg of fentanyl (p =0.8)usedre- spectively. There was no difference in the ODI between the two groups (HFNP = 18 +/À 13, LFNC = 17.5 +/À 9.5, p = 0.8). Questionnaires have not indicated any difference in how well procedures were tolerated. Conclusion: In this small pilot study, preliminary data suggest that HFNO and LFNC appear to be equivalent in their ability to maintain saturations during bronchoscopic procedures. Grant Support: Nil. Each line represents an individual case. Conclusions: In this small case series, changes in FOT parameters appear to correlate with improvements in RFT parameters. Changes in small airway function may be a mechanism, whereby patients with severe COPD benefit from ELVR. Grant Support: Nil.

TO 099 TO 100

MEASURING PLEURAL FLUID PH: MISCONCEPTIONS INTER-OBSERVER VARIABILITY IN THE RECOGNITION OF AMONGST PHYSICIANS BRONCHIAL SEGMENTAL ANATOMICAL VARIATIONS BETWEEN EXPERIENCED AND TRAINING NG L, DABSCHECK E, HEW M BRONCHOSCOPISTS Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital GALT L1,PAHOFFC1, RITCHIE A1,DUFFYD2,FIELDINGD1 1Royal Brisbane and Women’sHospital,2Royal Brisbane and Women’s 3 4 Introduction/Aim: Pleural fluid pH is important in the management of pleu- Hospital, Royal Brisbane and Women’sHospital, QIMR Berghofer Institute 5 ral effusions. The most accurate method of measurement is by blood gas of Medical Research, Royal Brisbane and Women’s Hospital analyser. Use of other methods may provide inaccurate results, potentially leading to diagnostic misclassification and impacting on patient care. This Introduction/Aim: The ability to correctly classify segmental bronchial study aims to determine whether a discrepancy exists between the actual mo- anatomy is extremely important for all forms of bronchoscopy, but can be very dality used to measure pleural pH and how clinicians believe it is measured. challenging. To correctly describe anatomical variations is likely related to how Methods: Seven hundred seventy-two Australian and New Zealand respi- well advanced trainees (AT) perform to experience. The aim was to identify ratory consultant physicians were contacted via email using the Thoracic So- the degree of correlation between bronchoscopists of differing experience. ciety of Australia and New Zealand register. Physicians were surveyed on Methods: Twelve months of standard bronchoscopy recordings were their clinical application of pleural pH and their laboratories’ method of mea- reviewed by four observers, two consultant bronchoscopists and two trainees surement. The identified laboratories were contacted by telephone to deter- in Thoracic Medicine. From a previous study, the two consultants had showed mine their actual approach to pleural fluid pH measurement. a high agreement; this was regarded as the gold standard. The AT’s had un- Results: One hundred sixty-one (21%) respiratory physicians completed dergone simulated training, followed by testing using the Bronchoscopy Skills, the survey. Ninety percent of the surveyed physicians use pleural fluid pH to and Task Assessment Tool then performed 250 bronchoscopies. manage complicated pleural effusions. Only 53% correctly identified blood Results: From 163 patients, there were 576 lobes to review. Overall, seg- gas analyser as the most accurate method of pleural pH measurement. mental anatomy was correctly identified in over 92.8% of all cases. The Fifty-four out of 56 laboratories surveyed measure pleural fluid pH. Blood gas greatest difficulty was encountered in the right upper lobe (87.3%) and the left analyser is used in 50% of the laboratories; 28% use pH indicator sticks, and lower lobe (91.8%). The average sensitivity for variations for all observers was 22% use pH metres. Risk of damage to the blood gas analyser machine was 91.9%, with a standard deviation of 1.1%. There was a high correlation identified as the primary barrier amongst 39% of laboratories that use either (>80%) between all observers in all lobes, except trainees fell to moderate pH indicator sticks or pH metres for pleural pH measurement. correlation (60–80%) in the right upper lobe. Results below show correlation Only 34% of physicians correctly identified the method of pleural pH measure- for the (right upper lobe and right lower lobe) using two indices of correlation ment used by their laboratory. Nineteen percent of physicians were incorrect —Fleiss’ unweighted kappa in normal text and improved kappa S in italics. in their assumption that their laboratory uses blood gas analysers for measurement of pleural pH. Conclusions: A large proportion of the physicians surveyed are unaware Observer Consultant A Consultant B Trainee C Trainee D of the method of pleural pH measurement in their laboratories and that blood gas analyser is the most accurate approach. Physicians may be making clin- Consultant A — 0.71, 0.84 0.69, 0.81 0.67, 0.93 ical decisions to manage complicated pleural effusions based on imprecise Consultant B 0.80, 0.92 — 0.81, 0.78 0.86, 0.86 results. Trainee C 0.79, 0.91 0.87, 0.90 — 0.76, 0.85 Grant Support: No research funding was obtained. — Declaration of Interest Statement: No conflict of interest. Trainee D 0.78, 0.97 0.91, 0.93 0.84, 0.93

Conclusions: Overall trainees performed very well, only differing from consultant where the complexity is greatest in the right upper lobe. Bronchial anatomy training was assisted in these AT’s by detailed intervention before and during bronchoscopy training. Grant Support: None.

TO 102 Asthma and Allergy 3 Oral Presentations

WESTERN ENVIRONMENTS/LIFESTYLES HAVE CHANGED UPPER AIRWAY MICROBIOTA IN CHINESE IMMIGRANTS TO 101 ZHANG X1,2,3,PEACOCKC4, FILIPOVSKA-NAUMOVSKA E1, SAIGANESH A1,5,CHENS2,KHOOS1,5, HALES B5,LESOUËFP1, ZHANG G1,2,5 1School of Paediatrics and Child Health, The University of Western Australia, INEQUALITIES IN ASTHMA CONTROL FOR MAORI ADULTS IN Perth, Australia, 2School of Public Health, Curtin University, Perth, Australia, NEW ZEALAND 3School of Biosystems Engineering and Food Science, Zhejiang University, Hangzhou,China, 4School of Pathology and Laboratory Medicine, The Univer- 1 2,3 3 4,5,6 7 INGHAM T ,BECKERTL ,MORANA, SAWYER S ,PETERSM, sity of Western Australia, Perth, Australia, 5Telethon Kids Institute, The 8 8 AMPRON R ,REDDELH University of Western Australia, Perth, Australia. 1Department of Medicine, University of Otago Wellington, Wellington, New 2 Zealand, Department of Medicine, University of Otago, Christchurch, Christ- Introduction/Aim: Our aim is to compare microbial 16S rRNA profiles in church, New Zealand, 3Respiratory Services, Canterbury District Health 4 pharyngeal swab samples in newly-arrived adult Chinese immigrants (living Board, Christchurch, New Zealand, Centre for Adolescent Health, Royal in Australia <6 months) and long-term Chinese immigrants (living in in Austra- Children’s Hospital, Melbourne, VIC, Australia, 5University of Melbourne, > 6 lia 5years). Melbourne, VIC, Australia, Murdoch Children’s Research Institute, Methods: Twenty-two long-term Chinese immigrants and 22 newly arrived Melbourne, VIC, Australia, 7Concord Repatriation General Hospital, Sydney, 8 Chinese immigrants were recruited and matched for age and gender. Pharyn- NSW, Australia, Woolcock Institute of Medical Research, University of Syd- geal swab samples were collected, and 16SrRNA was sequenced on Illumina ney, NSW, Australia MiSeq. Results: There was no significant difference in microbial diversity between Aim: This study aimed to compare asthma outcomes between Māori and newly arrived and long-term Chinese immigrants. At the phylum level, non-Māori in a representative population cohort of New Zealand adults with Fusobacteria was significantly increased (p = 0.010), and Thermi was signifi- current asthma. cantly decreased (p = 0.038) in long-term Chinese immigrants, compared with Methods: Data were obtained from an online survey using previously re- newly arrived Chinese immigrants. At the genus level, long-term Chinese im- 1 ported methods. Participants with current asthma were randomly selected migrants had an increased level of Tannerella (p = 0.025), Capnocytophaga from an online panel, with oversampling for Māori participants, and stratifica- (p =0.037), Leptotrichia (p = 0.023), Paracoccus (p = 0.049), Eikenella tion by age and gender based on national data for people with asthma. (p =0.001), Kingella (p = 0.043) and Desulfobulbus (p = 0.043), relative to Asthma symptom control was assessed by Asthma Control Test (ACT), clas- newly arrived Chinese immigrants. However, the levels of Deinococcus sified as well-controlled (20–25), not-well-controlled (16–19) and very-poorly- (p = 0.038 ) and Cloacibacterium (p = 0.018) were significantly lower in long- controlled (5–15). term than newly arrived Chinese immigrants. Predictive metagenomics analy- Results: Five hundred thirty-seven adults (91 [16.9%] Māori and 446 sis found that the scores for environmental information processing and signal- [83.1%] non-Māori) were included in the analysis. Māori respondents were ling molecules and interaction were higher (p = 0.038) in long-term immigrants younger than non-Māori respondents (median age group: 20–29 vs 40– than those in the newly arrived. 49 years, p = 0.0018). Significantly, more Māori than non-Māori were current Conclusions: Chinese immigrants, after living in a Western environment smokers (45.7% vs 20.6%, p < 0.0001). No significant differences in asthma (Australia) for more than 5 years, have increased microbial levels of medication over the past 12 months were observed between groups: 95% Tannerella, Capnocytophaga, Leptotrichia, Paracoccus, Eikenella, Kingella Māori and 91% non-Māori reported using a short-acting beta2-agonist and Desulfobulbus and decreased microbial levels of Deinococcus and (p = 0.279), with 70% Māori vs 68% non-Māori using any inhaled corticoste- Cloacibacterium. These changes in airway microbiota may contribute to the roid containing inhaler (p = 0.714). Overall self-reported health status was disparity of disease prevalences such as asthma and allergy between West- poorer amongst Māori (27.2% reported fair/poor health compared to 19.4% ern (developed) and Eastern (developing) environments. for non-Māori, p = 0.0376). Asthma symptom control was worse amongst Grant Support: TSANZ fellowship; Telethon Perth Children’s Hospital Māori, with 40.5% classified as having very-poorly-controlled, 29.4% not- Research Funds. well-controlled and 30.2% well-controlled asthma, compared with 17.9%, 17.7% and 64.4%, respectively, for non-Māori (p < 0.0001). From logistic regression, ethnicity (p = 0.0032), female gender (p = 0.0334) and older age (p = 0.0269) were significant predictors of urgent asthma-related healthcare, which was required by 33.7% Māori and 26.8% non-Māori. Similar proportions had a non-urgent asthma-related visit (59.4% vs 56.0%, p = 0.55). Conclusions: Māori adults experienced significantly poorer asthma control and overall health status and required more urgent healthcare for asthma than non-Māori participants. Further investigation is required to understand contrib- utors to these findings. 1HK Reddel et al., MJA, 2015, 202,492–7 Grant Support: AstraZeneca New Zealand.

TO 103 TO 104

NEUTROPHIL ACTIVITY IS HIGHER IN OVERWEIGHT, RESISTIN AND RESISTIN : ADIPONECTIN RATIO AS VERSUS HEALTHY-WEIGHT, ADULTS WITH ASTHMA, BUT PREDICTORS OF LUNG FUNCTION IN ASTHMA DECREASES FOLLOWING A 14-WEEK DIETARY INTERVENTION WOOD L1, BALLANTYNE D1,2, SCOTT H1, MCDONALD-WICKS L2, GIBSON P1,3 JENSEN M1,WOODL1,GIBSONP1,2,GARGM3 1Center for Asthma and Respiratory Diseases, University of Newcastle, 1Centre for Asthma and Respiratory Diseases, University of Newcastle, 2School of Health Sciences, University of Newcastle, 3Department of Respira- 2Department of Respiratory and Sleep Medicine, John Hunter Hospital, tory and Sleep Medicine, John Hunter Hospital 3Neutraceuticals Research, University of Newcastle Introduction/Aim: Adipokines such as resistin and adiponectin modify Introduction/Aim: Overweight and obesity is prevalent in adults with inflammation and may contribute to increased asthma risk and severity in asthma and associated with neutrophilic airway inflammation and oxidative obese people. The aim of this study was to examine plasma resistin and stress. The effect of dietary carotenoids in overweight/obese adults with resistin : adiponectin ratio: (1) in asthmatics compared to healthy controls, asthma is unknown. We aimed to (1) compare airway neutrophil markers, sys- (2) according to asthma severity, BMI and gender (3) following weight loss temic inflammation and carotenoid levels in healthy-weight versus overweight/ in obese asthmatics. obese adults with asthma and (2) examine the effects of a high, versus low, Methods: In a cross-sectional observational study of asthmatic adults fruit and vegetable diet on these markers in overweight/obese asthmatic (n = 96) and healthy controls (n = 46), plasma resistin and adiponectin were adults. measured. In a separate intervention study, obese asthmatic adults (n =27) Methods: In a cross-sectional analysis, sputum neutrophil elastase activ- completed a 10-week weight-loss intervention, and plasma resistin and ity, toll-like receptor (TLR)-4 gene expression and IL8 levels, plasma caroten- adiponectin were analysed. oids and systemic inflammation were compared between healthy-weight (BMI Results: Median plasma resistin and resistin : adiponectin ratio were <25 kg/m2) and overweight/obese (BMI ≥ 25kg/m2)adultswithasthma. higher in asthma compared to healthy controls (7.2 (4.8–9.6) (IQR) vs 4.8 À Changes in these biomarkers were then compared between overweight/ (3.7–7.3) ng/mL, p = 0.005 and 3.04 ± 0.58 vs 1.55 ± 0.23 ×10 3 (SEM), obese asthmatic adults randomized to a high (HFV) versus low (LFV) fruit p = 0.019, respectively) and further increased in subjects with a severe and vegetable diet for 14 weeks. asthma pattern. Resistin : adiponectin ratio was increased in obese asthma Results: Baseline sputum neutrophil elastase, TLR4 expression and IL8 compared to non-obese asthma and non-obese controls. Resistin : were higher in the overweight/obese (n = 106) versus the healthy-weight adiponectin ratio was increased in obese females, non-obese males and (n = 27) adults; conversely, plasma carotenoids were reduced. Following the obese males compared to non-obese females. In multiple linear regression 14-week RCT, neutrophil elastase decreased in the HFV (n = 33) versus models, both resistin and resistin: adiponectin were negative predictors of lung LFV (n =63)group(À28.5 (À350.4, 64.6) vs. 211.5 (À15.4, 1508.7) ng/mL, function. Following weight loss, resistin and resistin : adiponectin ratio were p = 0.045), as did CRP (À0.2 (À2.8, 0.8) vs. 0.8 (0.1, 4.9) mg/L, p = 0.014). unchanged. However, change in %body fat was associated with change in Lutein and alpha-carotene increased in the HFV versus LFV group. resistin : adiponectin ratio. Conclusions: Markers of airway neutrophils were raised in overweight/ Conclusion: Resistin : adiponectin ratio is increased in asthma and further obese adults with asthma; however, neutrophil activity reduced following a increased in subjects who are obese, have more severe disease and are 14-week high fruit and vegetable diet, while circulating carotenoids increased. male. As resistin and resistin : adiponectin ratio negatively predict lung func- Dietary intervention may be beneficial in obese adults with asthma. tion, these adipokines may provide a therapeutic target for obese asthma. Grant Support: NHMRC. Grant Support: HMRI Project grant. Declaration of Interest: None to declare.

TO 105 TO 106

A SOLUBLE FIBRE SUPPLEMENT REDUCES AIRWAY SEX HORMONES AND SYSTEMIC CYTOKINES ARE INFLAMMATION IN ASTHMA INDEPENDENT MODULATORS OF THE OBESE–ASTHMA PHENOTYPE WOOD L1,HALNESI1,2,BAINESK1,MCDONALD-WICKSL2,GIBSONP1,3 1Centre for Asthma and Respiratory Diseases, University of Newcastle, SCOTT H1,2,GIBSONP1,GRAGM3, UPHAM J2,WOODL1 2School of Health Sciences, University of Newcastle, 3Department of Respira- 1Centre for Asthma & Respiratory Diseases, The University of Newcastle, tory and Sleep Medicine, John Hunter Hospital 2Lung and Allergy Research Centre, The University of Queensland, 3School of Biomedical Sciences and Pharmacy, The University of Newcastle Introduction/Aims: Short chain fatty acids (SCFAs) are produced following fermentation of soluble fibre by bacteria in the gut. In animal models, both Introduction/Aim: Sex hormones and systemic inflammation have both dietary fibre and SCFA have been shown to have anti-inflammatory effects via been hypothesized to have a role in driving the obese–asthma association. activation of free fatty acid receptors, such as G protein coupled receptor 41 The purpose of this study was to examine the associations between sex hor- and 43 (GPR41 and GPR43). The aim of this study was to examine the acute mones, oral contraceptive pill (OCP) use and systemic and airway inflamma- effect of a single dose of soluble fibre on airway inflammation, including free tion, in non-obese and obese males and females with asthma. fatty acid receptor gene expression, in asthma. Methods: Non-obese (n = 42) and obese (n = 39) female and non-obese Methods: Adults with stable asthma consumed either a single meal con- (n = 25) and obese (n = 24) male adults with asthma were recruited. Females taining soluble fibre (3.5 g inulin) and the probiotics, Lactobacillus acidophilus were classified as reproductive aged (<50 years old; n = 36) or older strain LA5, Bifidobacterium lactis strain Bb12 and Lactobacillus rhamnosus (>50 years old; n = 45). In reproductive aged females, OCP use was 36.1% strain GG (LGG)(each ≥108 colony forming units)(n = 17), or an isocaloric con- (n = 13). Venous blood samples were analysed for sex hormones and inflam- trol meal, containing simple carbohydrates only (n = 12). Exhaled nitric oxide matory markers, while induced sputum cell counts were measured. was measured, and induced sputum was collected at 0 and 4 h, for differential Results: Obese reproductive aged females had elevated sputum %neutro- cell counts, measurement of sputum supernatant IL-8 concentrations and phils compared with non-obese reproductive aged females (45.4 ± 24.3% vs sputum cell GPR41/43 gene expression. 27.5 ± 17.5%, p = 0.016); however, there was no significant effect of obesity Results: At 4 h after the meal consumption, GPR43 gene expression was in older females (p = 0.087) or males (p = 0.620). Regression demonstrated upregulated in sputum cells compared to baseline in the soluble fibre, but not that lower testosterone, and higher CRP and IL-6, were predictors of higher the control group (median fold change: 6.3 (1.6–15.8) (IQR) versus 0.3 (0– sputum %neutrophils, while lower progesterone and higher CRP predicted 0.8), p = 0.004, respectively). Similarly, GPR41 gene expression was upregu- higher sputum neutrophil counts. BMI and age were not predictors of sputum lated in sputum cells at 4 h compared to baseline in the soluble fibre, but not neutrophils after adjusting for sex hormones, OCP use and systemic inflam- the control group (median fold change: 5.2 (3.9–23.5) versus 0.4 (0.3–3.3), mation. Females using the OCP had lower sputum %neutrophils than those p = 0.028, respectively). This corresponded with decreases in sputum total not using the OCP (23.2 ± 12.6% vs 42.1 ± 23.8, p = 0.015). cell count, neutrophils and macrophages, sputum IL-8 and exhaled nitric oxide Conclusions: Lower testosterone and progesterone, and higher CRP and following the soluble fibre meal. IL-6, are independently associated with increased neutrophilic airway inflam- Conclusions: Soluble fibre has acute anti-inflammatory effects in asth- mation in adults with asthma. Low-grade systemic inflammation and reduced matic airways. Long-term effects of soluble fibre as an anti-inflammatory ther- concentrations of sex hormones are common in obesity. Our findings suggest apy in asthma warrant further investigation. that both systemic inflammation and sex hormones, rather than obesity itself, Grant Support: John Hunter Hospital Charitable Trust Project Grant. may have an important role in driving the obese–asthma phenotype. Our observation that OCP use was associated with lower sputum neutrophils warrants further investigation. Grant Support: The University of Newcastle; HMRI/Greaves Family Early Career Support Grant; TSANZ/Astra-Zeneca Respiratory Research Fellowship.

TO 108 Physiology and Sleep 1 Oral Presentations

FORCED OSCILLATION TECHNIQUE MEASUREMENTS RELATE TO HYPERINFLATION AND LUNG VOLUME IMPROVEMENTS FOLLOWING LONG-ACTING TO 107 BRONCHODILATOR IN COPD

MILNE S1,2, HAMMANS C1,WATSONS1,FARAHC1,2,THAMRINC1, BRONCHODILATOR RESPONSES OF FORCED OSCILLATION KING G1,3 TECHNIQUE AND SPIROMETRY IN ADULTS WITH AND 1Woolcock Institute of Medical Research and Sydney Medical School, Univer- WITHOUT AIRFLOW OBSTRUCTION sity of Sydney, 2Department of Respiratory and Sleep Medicine, Concord Repatriation General Hospital, Sydney Local Health District, 3Department of JETMALANI K>1,THAMRINC1,FARAHC1,2,TOELLEB1,DIBAC1, Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local KING G1,3 Health District 1Woolcock Institute of Medical Research, University of Sydney, 2Respiratory Department, Concord Hospital, 3Respiratory Department, Royal North Shore Introduction/Aim: Long-acting bronchodilators (BD) are the mainstay of Hospital maintenance therapy for chronic obstructive pulmonary disease (COPD); however, the FEV1 response to BD in COPD correlates poorly with clinical Introduction/Aim: The forced oscillation technique (FOT) has been sug- outcomes. Hyperinflation and its improvement following BD are known to bet- gested to be more sensitive than spirometry in detecting changes in airway ter correlate with clinical parameters. Forced oscillation technique (FOT), a mechanics after bronchodilator (BD) administration in disease. We aimed to measure of complex lung mechanics, may provide additional insights into compare the BD responses in FOT and spirometry from a representative com- the physiological response to BD. We aimed to explore the relationship be- munity sample of healthy adults, and compared these to responses in sub- tween FOT and the lung volume response to long-acting BD. jects with obstruction. Methods: Subjects with COPD (N = 10, mean (SD) age 67 (7) years) of Methods: Subjects recruited from the general population had measures of moderate severity (mean (SD) percent predicted FEV1, %pred FEV1 64 spirometry and resistance (Rrs) at 6 Hz before and 15 min after inhalation of (19)) were administered a single inhaled dose of indacaterol. Standard lung 200 μg salbutamol. The normal predicted values of R were derived using pre- function and FOT were measured at pre-defined time intervals over 2 h. dictive equations of Brown et al.1 FOT resistance (R5), reactance (X5) and p area under the reactance curve Results: Three hundred seventy subjects were classified as healthy non- (AX) were examined at 5 Hz. < smokers, non-obstructed smokers, COPD, asthmatics, or asthma-COPD Results: From baseline to 2 h, indacaterol improved FEV1 (p 0.0001) as overlap (Table 1). Baseline %pred Rrs, correlated with %pred FEV1 in well as inspiratory capacity (IC)/TLC ratio, a measure of hyperinflation < smokers (r = À0.24, p = 0.004), asthmatics (r = À0.45, p = 0.03) and COPD (p 0.01). Both baseline %predFEV1 and FOT measurements correlated (r = À0.58, p = 0.011). There were significantly greater improvements in Rrs with baseline IC/TLC. Furthermore, baseline FOT measurements correlated in smokers (p < 0.001) compared to never smokers and significantly greater with the subsequent increase in IC/TLC ratio (i.e. improvement in hyperinfla- À improvements in Rrs and FEV1 in subjects with asthma (p < 0.001), COPD tion): R5, r =0.65,p = 0.042; X5, r = 0.63, p =0.048.Thisrelationshipwas (p < 0.02) and asthma-COPD overlap (p < 0.02), compared to non-smokers. not observed between baseline %predFEV1 and the subsequent change in Seven out of twenty-three asthmatics had a positive BD response on spirom- IC/TLC. The magnitude of change in IC/TLC correlated with the change in À etry (ATS/ERS criteria), and 8/23 had positive response in Rrs (ΔRrs >22%, X5 (r =0.66,p = 0.036) and AX (r = 0.68, p = 0.030), but not with change in derived from the 95th percentile in non-smokers). Seven out of eighteen FEV1. COPD subjects had a positive BD response on spirometry, and 2/18 had pos- Conclusions: These preliminary data suggest that FOT measurements re- itive response in Rrs. Five out of eighteen subjects with asthma–COPD over- late to hyperinflation and subsequent lung volume improvements in response lap had a positive BD response on spirometry, and 5/18 had positive response to long-acting BD in COPD, which is not necessarily reflected by the change in in Rrs. While 26/156 smokers had a positive response in Rrs, only 7/156 had a FEV1. The relationship between FOT measurements and the clinical re- positive BD response on spirometry. sponse to long-acting BD warrants further exploration. Conclusions: Bronchodilator responses measured by FOT are greater in subjects with obstructive disease compared to healthy. The proportion of subjects with positive BD response on FOT is greater than on spirometry in non-obstructive smokers. However, in those with obstructive disease, the proportion of subjects with positive BD on FOT and spirometry are similar. Grant Support: Nil.

Table 1. Lung function parameters before and after BD

Asthma- Healthy Smokers Asthma COPD COPD N =155 N =156 N =23 N =18 N =18

Age 63 (13) 63 (12) 63 (15) 69 (11) 68 (10) FEV1 % pred 104.3 100.1 88.6 77.2 69.2 (11.1) (12.8) (13.8) (22.9) (18.4) FVC % pred 104.3 102 93.1 93.3 87.5 (13.1) (12.8) (13.7) (20) (25.2) Rrs cm.H20. 3.2 3.5 (1.1) 4.3 4.4 4.9 (1.3) s/L (0.85) (1.3) (1.7) Rrs % pred 93.4 (28) 101.3 120.8 131.5 135.4 (35) (40) (54) (44) ΔFEV (% 2.8 (5.9) 2.8 (5.4) 9.7 7.9 6.3 (6.2) change) (8.5) (6.4) ΔRrs (% 3.5 10.1 18.1 12.1 14.8 change) (15.1) (16.4) (17.2) (13) (11.2)

Mean (SD) 1Brown NJ. Reference equations for respiratory resistance and reactance in adults. Repir Physiol Neurobiol;172 (13):p162–8.

TO 109 TO 110

EXPIRATORY FLOW LIMITATION IS RELATED TO SYMPTOMS FREQUENCY-DEPENDENT PENETRANCE OF FORCED AND PREDICTS FUNCTIONAL OUTCOMES OF PULMONARY OSCILLATIONS IN THE LUNG REHABILITATION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE ZOSKY G1,THURGOODJ2,DUBSKYS2, UESUGI K3,CURTISM2, SAMARAGE C4, THOMPSON B5,FOURASA4 ZIMMERMANN S1,3,4, GANDERTON L2, SCOTT L2,FRASERA2, 1University of Tasmania, Tasmania, Australia, 2Monash University, Victoria, BERTOLIN A1,WATTSJ1,CHANA1,2,3,4,THAMRINC1,KINGG1,3,4 Australia, 3SPring-8/JASRI, Japan, 44Dx Pty Ltd, Victoria, Australia, 5The 1Woolcock Institute of Medical Research, Glebe, NSW 2037, Australia Alfred Hospital, Victoria, Australia Woolcock Institute of Medical Research, 2Department of Pulmonary Rehabil- 3 itation, Royal North Shore Hospital, St Leonards, NSW 2065, Australia, De- Introduction/Aim: The forced oscillation technique is a common method partment of Respiratory Medicine, Royal North Shore Hospital, St Leonards, for assessing lung mechanics. Multi-frequency signals are used to probe the 4 NSW 2065, Australia, Northern Clinical School, University of Sydney, NSW function of different regions of the respiratory tree. Inferences are then made 2006, Australia regarding changes in lung mechanics based on our theoretical understanding of the frequency-dependent response of the lung to pressure oscillations. The Introduction/Aim: Exertional dyspnoea is a hallmark symptom of chronic aim of this study was to directly visualize the frequency-dependent penetrance obstructive pulmonary disease (COPD) often causing exercise limitation. Ex- of a multi-frequency forced oscillation signal in order to improve our under- piratory flow limitation (EFL) is a pathophysiological characteristic of COPD standing of the anatomical variation in respiratory impedance. that can be measured non-invasively with the forced oscillation technique Methods: Male BALB/c mice were anaesthetized, tracheostomized, (FOT). EFL may increase symptoms resulting in exercise limitation. We hy- suspended vertically and mechanically ventilated. During 10-s periods of ap- pothesized that EFL is related to and predicts symptoms and functional out- noea, a forced oscillation signal composed of seven frequencies ranging from comes of pulmonary rehabilitation. 2 to 20.5 Hz was delivered to the lung via the tracheal cannula. Lung images Methods: Fourteen COPD patients without cardiac failure or orthopaedic were simultaneous collected during the delivery of the oscillatory signal, at 100 comorbidity affecting exercise performance were recruited from the Royal frames per second, using phase-contrast X-ray imaging at the SPring-8 syn- North Shore Hospital Pulmonary Rehabilitation department. Symptoms were chrotron (Japan). X-ray velocimetry was used to assess local tissue motion assessed by St George’s Respiratory Questionnaire (SGRQ) and functional at 1000 locations across the lung. outcomes by 6-min walk distance (6 MWD). EFL was defined as difference Results: There were clear frequency-dependent anatomical differences in between inspiratory and expiratory FOT reactance. We measured spirometry, the penetrance of the oscillations. Overall, the bulk of the lung motion resulting 60 s tidal breathing FOT at 5 Hz, 6 MWD and SGRQ. FOT, 6 MWD and SGRQ from the pressure oscillations was, not surprisingly, localized in the dependent were repeated at the end of rehabilitation and at 3 months. Pearson correla- regions of the lung; with lower frequencies penetrating deeper into the lung pa- tions were used to assess the relationship between EFL with SGRQ and renchyma. The non-dependent regions (lung apex) showed very little motion 6 MWD at baseline and between EFL and changes in SGRQ and 6 MWD im- in response to oscillations at any frequency. Motion of the lung at the primary mediately and 3 months post-rehabilitation. Pre- and post-rehabilitation differ- cardiac frequency was large relative to the expansion induced by the forced ences were evaluated using paired t-tests. oscillations and, interestingly, was observable across the lung. Results: Mean age was 75.4 ± 6.3 years and FEV1 was 55.4 ± 17.7%pre- Conclusions: These observations provide insight into the regional fre- dicted. At baseline, EFL related to SGRQ (r =0.80,p = 0.003) although not to quency-dependent penetrance of forced oscillations. In particular, the heart 6MWD(r = À0.06, p = 0.85). 6 MWD improved immediately post-rehabilita- has a strong influence on lung motion, and there is a lack of penetrance of tion (mean 412.6 ± 90.7 m and 462.2 ± 124.3 m, p = 0.01), and baseline EFL the oscillations to the non-dependent regions of the lung. predicted improvement in 6 MWD at 3 months post-rehabilitation (r = À0.64, Grant Support: Nil. p = 0.04). While there was no significant improvement in EFL, inspiratory reac- À tance improved (mean À2.40 ± 1.04 cmH2O * s * L 1 and À2.05 À ±0.88cmH2O*s*L 1, p =0.008). Conclusions: EFL may contribute to impaired quality of life in COPD, but does not change with pulmonary rehabilitation despite improvements in SGRQ and 6 MWD. This suggests that the presence of EFL is a marker of potential benefit of pulmonary rehabilitation in COPD. The mechanisms underlying this association, and in the improvement in inspiratory reactance require further study. Conflict of interest: None. Support: NHMRC Scholarship.

TO 112 Chronic Obstructive Pulmonary Disease 3 Oral Presentations CIGARETTE SMOKE EXTRACT INDUCES EXTRACELLULAR TRAP FORMATION WITH PROTEASE EXPRESSION THAT IS INHIBITED BY DNASE TO 111 KING P1,2, SHARMA R1,2,O’SULLIVAN K2, BARDIN P1,2, HOLDSWORTH S2 1Monash Medical Centre, 2Monash University HEALTHY GUT MICROBIOTA AMELIORATES EXPERIMENTAL CHRONIC OBSTRUCTIVE PULMONARY DISEASE Introduction/Aim: The production of proteases by smoking has a primary role in the pathogenesis of emphysema. How smoking induces lung protease production is not well defined. Extracellular traps have been recently recog- GELLATLY S1,DENNISP2,JARNICKIA1,LACHNERN3,WOODD3, 1 1 1 1 4 nized to be produced by neutrophils (NETs) in response to stimuli such as in- FRICKER M , BUDDEN K , LIU G , KEELY S ,MORRISONM,WILLNER fections. These extracellular traps express proteases and can be inhibited by D3,COOPERM5, HUGENHOLTZ P3, HANSBRO P1 1 DNase. The aims of this study was to define if cigarette smoke extract (CSE) Centre for Asthma and Respiratory Disease, University of Newcastle and induces (1) the formation of extracellular traps by macrophages (METs) and Hunter Medical Research Institute, 2School of Agriculture and Food Sciences, 3 neutrophils (NETs) which co-express proteases and (2) whether this process University of Queensland, Brisbane, QLD, Australia, Australian Centre for can be inhibited by the addition of DNase. Ecogenomics, School of Chemistry and Molecular Biosciences, University of 4 Methods: Bronchoalveolar lavage was used to obtain macrophages from Queensland, Brisbane, QLD, Australia, The University of Queensland both control and COPD subjects and neutrophils were obtained from periph- Diamantina Institute, Translational Research Institute, Woolloongabba, QLD, 5 eral blood in healthy controls. Cells were exposed to CSE before being la- Australia, Institute for Molecular Bioscience, University of Queensland, belled with a variety of dyes for chromatin, macrophage metalloproteinases Brisbane, QLD, Australia 9 and 12 (MMP9 and 12), neutrophil elastase (NE), citrillinated histone, PAD 2 and PAD4. Cells were analysed for their expression of extracellular traps Introduction/Aim: Recent technological advances have led to the assess- by confocal microscopy. ment of the microbiome and implicated it in health and disease states. It is now Results: Results demonstrated that CSE caused a significant increase in established that there is infectious and inflammatory cross talk between the MET and NET production with protease expression (MMP9/12 and NE), both lung and gut, and so, changes in gut microbiomes may potentially induce sys- in COPD subjects and healthy controls. This increase in NET and MET pro- temic inflammation that can impact respiratory disease. We sought to under- duction with protease co-expression was significantly inhibited by the addition stand how the microbiome changes in response to cigarette smoke of DNase. (All results; p < 0.05.) exposure in a model of COPD and whether modulation of the microbiome Conclusions: Cigarette smoke extract induces extracellular trap formation could retard disease development. with protease co-expression, which can be inhibited by DNase. These finding Methods: C57BL/6 mice were exposed to cigarette smoke (CS) 5 days/ have important implications for both the pathogenesis and treatment of week for 8 weeks. Fresh faeces were collected once per week to assess emphysema. changes in the gut microbiome. The microbiome of air-exposed and CS-exposed controls was modulated by transferring faeces in dirty bedding or by faeces given by gavage to recipient air and CS-exposed mice and any effect of modulation on disease development examined. Lung function and inflammation were assessed after 8 weeks and the bacterial microbiome analysed by DNA sequencing of 16S ribosomal genes. Results: The faecal microbiome of air and CS-exposed mice was markedly different. Mice that received a faecal transplant (via dirty bedding or gavage) had a microbiome in between that of both control groups, indicating that the microbiome could be modulated. CS-exposed mice developed increased lung capacity and inflammation, the severity of which was significantly reduced in CS-exposed mice that had received a microbiome transplant from healthy mice. Specific taxa were strongly associated with either the disease or health state. Conclusions: CS exposure dramatically altered the microbiome. Modula- tion of this microbiome retarded the development of disease features in an experimental model of COPD. The results suggest a potential role for gut microbiota interventions for the treatment of inflammatory lung diseases. Grant Support: Rainbow Foundation, HMRI, NHMRC. SLG received a Lung Foundation Australia COPD Fellowship. Conflict of Interest: None.

TO 113 TO 114

INFLAMMATION PARADOX—A DETAILED ANALYSIS OF EXTRACELLULAR SUPEROXIDE DISMUTASE 3 IS REQUIRED INFLAMMATORY PROFILE IN THE LARGE AND SMALL TO EFFICIENTLY CLEAR STREPTOCOCCUS PNEUMONIA IN AIRWAY WALL IN MILD TO MODERATE COPD PATIENTS THE LUNG

EAPEN M1,MCALINDENK1,TAND1,MULLERH1,SOHALS1,2,WALTERSE1 ANTHONY D1,3,WIJBURGO2,YATMAZS3, DUNNE E4,SEOWH3, 1NHMRC CRE, Breathe Well, School of Medicine, University of Tasmania, SATZKE C4, ANDERSON G1, BOZINOVSKI S3 Tasmania, 2School of Health Sciences, University of Tasmania, Launceston, 1Department of Pharmacology and Therapeutics and The Lung Health Tasmania Research Centre, University of Melbourne, 2Department of Microbiology and Immunology, University of Melbourne, 3School of Health Sciences, Health 4 Aim: We recently reported hypo-cellularity of the lamina propria (LP) in Innovations Research Institute RMIT University, Murdoch Children’s large airway biopsies in COPD. We have now counted cell differentials in Research Institute the LP of large airways (LA) versus small airways (SA) from mild to moderate COPD current smokers (CS) and ex-smokers (ES) and compared them to tis- COPD is underlined by inflammation and excess oxidative stress that is com- sues from normal lung function smokers (NLFS) and normal controls (NC). monly associated with a deficiency to control pathogenic airway microbes Methods: For LA, we obtained endobronchial biopsies and, for SA, such as Streptococcus pneumonia (Spn). Spn is particularly resistant to oxi- resected lung tissues. Immuno-staining was done for CD68+ macrophages, dant dependent killing and is a common occurrence in COPD. Chronically col- neutrophils (neutrophil elastase), CD4 and CD8 for T cells. Cell counts were onized COPD patients are more likely to be frequent exacerbators, show done in the LP up to 150 micron deep for LA and 100 micron for SA, using im- accelerated disease and have higher rates of community-acquired pneumo- age PROPLUS 7.0 software and cells per square millimetre area were nia (CAP) largely due to ineffective vaccines, emergence of antibiotic resis- calculated. tance and immunosuppressive treatments such as glucoccorticoids. Given Results: Similar to our hypo-cellularity findings with LA we observed de- the lack of effective treatments for Spn colonization in COPD, it is important crease in total cellularity in SA LP in NLFS, COPD-CS and ES subjects com- to understand the mechanisms driving this dysfunctional immunity. SOD3 is paredtoNC(p < 0.001). Cellularity in LA was least in COPD-CS (p < 0.01), the major lung extracellular antioxidant, and gene polymorphisms in COPD while in SA, cellularity was similar across smoker/COPD groups. In LA, com- are associated with lower lung function and increased hospitalizations. pared to NC, neutrophils were decreased in COPD-CS (p < 0.01), while SA Aim: Our aim is to determine the mechanisms by which oxidative stress neutrophil counts were not abnormal. Compared to NC, LA macrophage num- compromises Spn clearance. < Methods: bers in COPD was significantly lower (p 0.05), with SA macrophage num- A mouse model of transientÀ À Spn infection in a high oxidative bers unchanged. A significant increase was observed in SA CD8+ cells in stress environment (C57BL/6 SOD3 / mice) was used. Spn (EF3030, 19F) both NLFS (p < 0.01) and COPD-CS (p < 0.001), while in LA, these lympho- was intranasally administered, and at specific time points, airway immune cyte numbers were unchanged across the groups. CD4 + T cells in COPD LA cells were analysed by flow cytometry. Plaque forming unit assays was used were significantly decreased (p < 0.01). Notably in both LA and SA, the num- to measure bacterial burden. À À ber of immune-stained inflammatory cells constituted only 15–20% of total cell Results: SOD3 / mice showed significantly higher Spn burden at day 7, numbers. that coincided with significantly less recruited lung neutrophils, altered macro- Conclusions: We believe the current dogma about airway wall inflamma- phage phenotype and a failure to expand IL-17A+gdT cells. Analysis of effec- tion in COPD is oversimplified and misleading at least in early stages of the tor molecules demonstrated a significant reduction in CCL2 (MCP-1), IL-23 disease. The majority of the cells in the LP did not stain with the antibodies and IL-1b protein levels due to reduced monocytic recruitment. used and are likely to be resident stromal cells. Conclusion: Excessive oxidative stress alters early Spn immunity ulti- Grant Support: NHMRC ID1001062. mately leading to compromised Spn clearance. Increasing SOD3 function in Conflict of Interest:Nil. COPD may offer a novel strategy to targeting Spn colonization and community-acquired pneumonia risk by restoring beneficial immunity to pathogenic microbes. Grant Support: NHMRC.

TO 115 TO 116

STEROID RESISTANCE IN COPD IS ASSOCIATED WITH TOLL-LIKE RECEPTOR 7 PROMOTES CIGARETTE-SMOKE IMPAIRED MOLECULAR CHAPERONE HSP90 EXPRESSION INDUCED EMPHYSEMA-LIKE ALVEOLAR ENLARGEMENT IN BY PRO-INFLAMMATORY LYMPHOCYTES CHRONIC OBSTRUCTIVE PULMONARY DISEASE

HODGE G1,2,JERSMANH1,2,HOLMESM1,2, ROSCIOLI E1,2,TRANH1,2, STARKEY M1,2,6,HAWT1,2,6,PAVLIDISS3,MONONAIRP1,2,LIUG1,2, REYNOLDS P1,2,HODGES1,2 HANISH I1,2,4, KIM R1,2,MIYAKEK5,ADCOCKI3,FOSTERP1.2,HORVAT 1Lung Research, Hanson Institute; Thoracic Medicine, Royal Adelaide Hospi- J1,2, HANSBRO P1.2 tal, 2Department of Medicine, University of Adelaide 1Priority Research Centre for Asthma and Respiratory Diseases, Hunter Med- ical Research Institute, New Lambton Heights, New South Wales, Australia, 2 Introduction/Aim: Corticosteroid resistance is a major barrier to effective School of Biomedical Sciences and Pharmacy, Faculty of Health and Medi- 3 treatment of COPD and is associated with steroid resistant CD28nullCD8+ cine, University of Newcastle, Callaghan, New South Wales, Australia, The pro-inflammatory lymphocytes. These senescent lymphocytes express de- Airways Disease Section, National Heart and Lung Institute, Imperial College 4 creased levels of HDAC2 (a nuclear enzyme required by corticosteroids to London, London, UK, Department of Microbiology, Faculty of Biotechnology switch off activated inflammatory genes) and glucocorticoid receptor (GCR). and Biomolecular Sciences, Universiti Putra Malaysia, Serdang, Selangor, 5 GCR must be bound to the molecular chaperones heat shock proteins Malaysia, Department of Microbiology and Immunology, The Institute of 6 (HSP)70 and HSP90 to acquire a high-affinity steroid binding conformation Medical Science, The University of Tokyo, Minatoku, Tokyo, Japan, These and traffic to the nucleus. We hypothesized that there is a loss of HSP70/90 authors contributed equally from these lymphocytes that contribute to steroid resistance in COPD. Methods: Blood was collected from COPD (n = 10) and aged-matched Introduction/Aim: Toll-like receptor 7 (TLR7) is an intracellular pattern rec- controls (n = 10). Cytotoxic mediators (perforin and granzyme B), intracellular ognition receptor that is crucial for immune responses to single-stranded RNA pro-inflammatory cytokines (IFNγ and TNFα) and expression of CD28, GCR, viruses. The role of TLR7 in pathogenesis of chronic obstructive pulmonary HSP70 and HSP90 were determined T and NKT-like cells in the presence disease (COPD) is unknown. We aimed to characterize the role of TLR7 in ex- of ±10 μM prednisolone and 2.5 ng/mL cyclosporine A (binds to GCR- perimental and human COPD. À À HSP70/90 complex) using flow cytometry, western blot and fluorescence Methods: Wild-type (WT) or TLR7-deficient (TLR7 / )BALB/cmicewere microscopy. subjected to an 8-week nose-only cigarette smoke (CS)-induced model of ex- Results: A loss of expression of HSP90 and GCR from CD28null CD8+ T perimental COPD. Other groups of WT mice were treated acutely (during the and NKT-like cells in COPD was noted (HSP70 was unchanged). A significant last 2 weeks of CS-exposure) or chronically (8 weeks without CS-exposure) correlation was found between loss of HSP90 expression and the percentage with a synthetic TLR7 agonist (imiquimod, 50 μgin50μL saline, intranasally, of CD28null CD8+ T and NKT-like cells producing IFNγ or TNFα in all subjects 5×/week). To determine the therapeutic potential of targeting TLR7, WT mice (e.g. COPD: R = À0.763, p = 0.007 for T-cell IFNγ). Up-regulation of HSP90 were treated with neutralizing monoclonal antibody (4 mg/kg, intravenously, and an associated decrease in pro-inflammatory cytokine production were once a week). TLR7 expression was assessed in pre-existing microarray data À found in CD28nullCD8+ T and NKT-like cells in the presence of 10 6 Mpred- from COPD patients and non-COPD subjects. nisolone and 2.5 ng/mL cyclosporine A. Results: TLR7 mRNA expression was increased in lung of CS-exposed Conclusions: Loss of HSP90 from cytotoxic/pro-inflammatory mice and lung samples from human COPD patients. Immunohistochemistry

CD28nullCD8+ T and NKT-like cells could contribute to steroid resistance in confirmed that TLR7 was expressed on small airway epithelial andÀ À paren- COPD. Alternative treatment options, such as combined prednisolone with chyma-associated inflammatory cells in CS-exposed mice. In TLR7 / mice, low-dose cyclosporine A, that up-regulate HSP90 and inhibit these pro-inflam- CS-induced weight loss was reduced, whilst pulmonary inflammation was À À matory cells, may reduce systemic inflammation in COPD. notaltered.CS-exposedTLR7 / mice had reduced emphysema-like alveolar enlargement and improved lung function. Concurrent with the alveolar en- À largement, CS-induced apoptosis in lungs was significantly reduced in TLR7 / À mice. Consistent with these observations, mice treated acutely or chronically with the TLR7 agonist had increased emphysema-like alveolar enlargement and alveolar epithelial cell apoptosis. There was a synergistic effect of CS-exposure and agonist treatment on alveolar enlargement. Importantly, treatment with neutralizing anti-TLR7 antibody significantly reduced emphysema-like alveolar enlargement and apoptosis. Conclusions: Our study is the first to show that TLR7 plays an important role in the pathogenesis of COPD, and immunomodulation of the TLR7 signalling pathway may be a new therapeutic target for emphysema. Grant Support: NHMRC. Conflict of interest: None.

TO 118 Respiratory Infectious Diseases 2 Oral Presentations

ANTIBIOTIC OVER-TREATMENT OF MILD TO MODERATE COMMUNITY ACQUIRED PNEUMONIA IN A TERTIARY CENTRE TO 117 SHIH S1,THIENF1,WARBURTONE2, BARTOLO C1, LEE C1,YOUNGA1 1Eastern Health, 2Monash University IMPROVING NARROW SPECTRUM ANTIMICROBIAL PRESCRIBING FOR COMMUNITY ACQUIRED PNEUMONIA Introduction/Aim: Current guidelines recommend assessment of the severity of community acquired pneumonia to assist with the choice of initial an- AHMAD W1,JEEA1,HARRISB1,HIBBERTM1, CASULA L2, FIGTREE M3 tibiotic therapy. Our aim was to evaluate the usage of pneumonia severity 1Royal North Shore Hospital, NSW, 2Royal North Shore Hospital, 3Royal stratification tools and subsequent initial antibiotic selection for community ac- North Shore Hospital quired pneumonia at our tertiary centre. Methods: A retrospective audit reviewing all Eastern Health medical record Aim: Our aim is to describe antibiotic use in community-acquired pneumo- data for all inpatients treated for community acquired pneumonia during June nia (CAP) at a major tertiary hospital pre- and post-implementation of an anti- 2012. Data were collected to determine pneumonia severity according to two microbial stewardship program (AMS). commonly used severity stratification methods, CORB (score based on the Method: We conducted a single-centre, retrospective audit of patients presence of confusion, low oxygen saturation, tachypnoea and low blood admitted to Royal North Shore Hospital with CAP from October to December pressure) and SMART-COP (score based on the presence of hypotension, 2012 and for the same period in 2014. Cases were identified by the principle multi-lobar chest-xray changes, low albumin, tachypnoea, tachycardia, confu- DRG E62. The three highest volume admitting specialties, Respiratory, sion, low oxygen saturation and low pH), along with antibiotic treatment and General Medicine and Geriatrics, were used for this analysis. Relevant patient used to evaluate pneumonia severity stratification usage, appropriateness of characteristics, antibiotic use and clinical outcomes were measured. A retro- initial antibiotic selection and impact on patient length of stay. spective SMART-COP score was calculated for all cases. Results: Eighty-five patient records were reviewed. No patient records in- Results: In 2012, of 98 admitted CAP case, (Respiratory 57, General Med- dicated that pneumonia severity stratification tools had been applied. For mild icine 24 and Geriatrics 17), there were 69 mild, 20 moderate and 9 severe cases 5% (CORB) and 4% (SMART-COP) received appropriate antibiotic cases. In 2014, 100 CAP cases were identified (Respiratory 53, General Med- therapy. For moderate cases, 23% (CORB) and 20% (SMART-COP) were ap- icine 26 and Geriatrics 21) with 83 mild, 10 moderate and 7 severe cases. In propriately treated. For severe cases, 64% (CORB) and 82% (SMART-COP) 2014, IV third generation cephalosporins were prescribed in 37% of all mild were appropriately treated. For mild cases that were given inappropriate anti- cases compared to 77% in 2012—a reduction of 48%. In contrast, the use biotic therapy, 92% (CORB) and 94% (SMART-COP) were classified as being of narrow spectrum penicillins for mild CAP (IV and oral) increased from over-treated. 16% in 2012 to 54% in 2014. Conclusions: Pneumonia severity was not documented in our tertiary cen- Additionally, for all audited patients, total days of intravenous azithromycin for tre. Mild and moderate pneumonia were frequently over-treated with antibi- atypical cover decreased from 147 days in 2012 to 69 days in 2014—areduc- otics more suited for severe pneumonia. Severe cases were in general tion of 53%. appropriately treated. Education regarding assessment of pneumonia severity The 2014 results showed a significant difference in the average length of stay and appropriate choice of antibiotic is currently being undertaken at our of patients with mild CAP receiving penicillin-based treatment versus third centre. generation cephalosporin (4.27 vs. 6.0 days, respectively). Grant Support: No declaration. Conclusions: This study has demonstrated an increase use of narrow spectrum antimicrobials with reduction in length of stay for mild CAP and a reduction in the overall use of IV atypical antimicrobials post-implementation of an AMS program. The significant support of specialist clinicians ensures the uptake and success of AMS program.

TO 119 TO 120

VIRAL INFLUENZA INDUCES MACROPHAGE PNEUMOCOCCAL CONJUGATE VACCINES IN THE EXTRACELLULAR TRAP FORMATION WITH CELL DEATH PROTECTION OF PNEUMOCOCCAL PNEUMONIA (CAP) IN THAT CAN BE INHIBITED BY DNASE THE ELDERLY

KING P1,2, SHARMA R1,2,O’SULLIVAN K2,HOLDSWORTHS2, BARDIN P1,2 COOPER C1,MCINTYRER2,HEYWOODA2 1Monash Medical Centre, 2Monash University 1Candidate, Master of Philosophy, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia, 2School Introduction/Aim: A major cause of death in viral influenza infection is of Public Health and Community Medicine, The University of New South secondary bacterial pneumonia, and this pneumonia is thought to be due to Wales, Sydney, Australia epithelial damage. However, lung macrophages also play a critical role in preventing bacterial infection. The aims of this study was to demonstrate that Background: Streptococcus pneumoniae infection is a major cause of dis- influenza infection causes (1) death of macrophages by the novel mechanism ease worldwide and one of the most common causes of severe pneumonia. of extracellular trap formation, and (2) this cell death can be prevented by the As pneumococcal capsular antigens induce serotype specific antibodies, the addition of DNase. available vaccines (polysaccharide and polysaccharide conjugated) are both Methods: Human and mouse macrophages that were obtained from bron- able to produce a serological response and are efficacious against invasive choalveolar lavage were infected with a variety of different strains of viral influ- pneumococcal disease. In contrast to the 23-valent non-conjugated vaccine, enza. Infectivity of the macrophages was measured by the uptake of the conjugated vaccines activate B- and T-cell immune pathways leading to influenza. Macrophages were labelled with chromatin, matrix metalloprotein- immune memory. They therefore elicit strong adaptive and booster response. ase 12, citrillinated histone and PAD2, and macrophage extracellular trap Australia’s ageing population and projected future population growth in the (MET) formation was assessed using confocal microscopy for the extracellu- elderly population presents challenges to health care. This demographic shift lar localization of these dyes. Human recombinant DNase (as given in the is seen globally, and preventative health strategies are imperative for healthy form of Pulmozyme) was added at the time of infection. Cell death was ageing. The elderly are at risk of many preventable diseases including pneu- assessed by annexin V expression and propidium iodide labelling. mococcal disease. This study aimed to review the evidence of the efficacy and Results: The results showed that influenza infection induced MET forma- effectiveness of the conjugate pneumococcal vaccine PCV13 licenced for tion in both human and mouse cells (p < 0.01). The formation of METs was adults greater than 50 years in 2011. significantly correlated with the infectivity (p < 0.05), and there were differ- Methods: We performed a systemic review of evidence for efficacy and ef- ences in MET formation between specific influenza strains (p < 0.01). The ad- fectiveness of the conjugate vaccine against community-acquired pneumonia dition of DNase significantly reduced MET formation (p < 0.001), and this (CAP) in the elderly in any setting. A search strategy identified relevant litera- effect of DNase also caused a significant reduction in death of the influenza- ture in which clinical outcomes of pneumonia in elderly populations (aged infected macrophages (p < 0.01). 65 years or older) were described. Relevant outcomes in pneumococcal vac- Conclusions: Influenza induces MET formation that results in death of the cinated populations compared to placebo or alternative vaccines were infected macrophages, and this effect can be inhibited by the addition of DN- included in both clinical trial and observational settings. Results of the studies ase. The findings have relevance for secondary bacterial pneumonia that may were summarized and a critically interpretation provided. occur with influenza infection. Results: A single large RCT showed efficacy of PCV13 in prevention of vaccine type community-acquired pneumococcal pneumonia (45.6%, 95% CI 21.8–62.5%) and invasive pneumococcal disease (75.0%, 95%CI 41.4–90.8%). No observational studies have been published to date. Conclusions: Evidence suggests the conjugate vaccine has significant efficacy against pneumonia. Changes in pneumococcal serotypes over time pose an additional challenge for vaccines and will need to be the focus of future research. Declaration of Interest Statement The presenter is an employee of Pfizer who is a manufacturer of pneumococcal vaccine. However, this project is being conducted as part of the investigator’s requirements for a Master of Philosophy.

TO 120a TO 120b

EXHALED VIRUSES ARE REPRESENTATIVE OF LOWER INFLUENZA A VIRUS (IAV) CAUSES VASCULAR RESPIRATORY TRACT INFECTION ENDOTHELIAL CELL OXIDATIVE STRESS VIA NOX2 NADPH OXIDASE MITCHELL A1,2,LAMH3,PETERSM3,4,MORGANL3,4,OLIVERB1,2 1School of Medical and Molecular Biosciences, University of Technology Syd- HENDRICKS K1,TOE1, BROUGHTON B1, PESHAVARIYA H2, VLAHOS ney, NSW, Australia, 2Woolcock Institute of Medical Research, University of R3, SELEMIDIS S1 Sydney, NSW, Australia, 3Department of Thoracic Medicine, Concord Repa- 1Infection and Immunity Program, Biomedicine Discovery Institute, Depart- triation General Hospital, Concord, NSW, Australia, 4School of Medicine, Con- ment of Pharmacology, Monash University, Clayton, VIC, Australia, 2Centre cord Clinical School, University of Sydney, NSW, Australia for Eye Research Australia, University of Melbourne, East Melbourne, VIC, Introduction/Aim: Viral respiratory tract infections are responsible for a signif- Australia, 3Respiratory Research Group, RMIT University, Bundoora, VIC, icant healthcare burden especially in the winter months. Identification of the Australia causative virus can be problematic as sample collection methods are limited. Introduction/Aim: Emerging evidence suggests that vascular endothelium Currently, the gold standard for sampling the lower respiratory tract is bron- contributes to IAV-induced lung inflammation. However, the mechanisms by choalveolar lavage (BAL), however this is a time consuming, expensive and which this occurs remain largely unknown. IAV has been shown to enter cells invasive method. To determine if exhaled breath collected in an electret filter via endocytosis and activate toll-like receptors (TLRs), resulting in an increase was comparable to BAL as a way of detecting and identifying lower respiratory in inflammatory cytokines. Previously, we have shown that IAV infection in tract viruses. macrophages results in an increase in endosomal reactive oxygen species Methods: Patients undergoing bronchoscopy for any reason were recruited (ROS) production by Nox2 oxidase, and that Nox2 deficiency is protective and completed three forced expiratory manoeuvres into a spirometry mouth- against IAV-induced inflammation. The aim of this study was to determine if piece immediately prior to preparation for the bronchoscopy. Samples of lower IAV causes endothelial cell oxidative stress, and to establish the subcellular respiratory tract secretions were obtained following a 10mL BAL. A panel of localization and enzymatic source. respiratory viruses (Human Rhinovirus, Respiratory Syncytial Virus, Influenza Methods: Human microvascular endothelial cells (HMEC), and wild-type and A, Influenza B, Parainfluenza Virus 1, 2, 3 and Human Metapneumovirus) was Nox2-/- mouse lung endothelial cells (MLEC) were infected with IAV (Hong assayed using RT-PCR in each matched sample. Kong X-31; multiplicity of infection 10) or treated with TLR3 agonist, Results: 50 participants provided both exhaled breath and BAL samples. So polyinosinic:polycytidylic acid (poly I:C) (100μg/ml), at various time points. far, 10 of these samples have been processed using RT-PCR, and only Rhi- Confocal microscopy was used to image early endosomes, IAV nucleoprotein novirus was detected at high enough levels in these patients for comparison. and Nox2. The fluorescent probe OxyBURST was used to detect endosomal ROS. 50% were positive in their exhaled breath samples, and 40% were positive in Results: There was co-localisation of early endosomes with both influenza the BAL sample. The concordance between exhaled breath and BAL viral nucleoprotein and Nox2 in X-31-infected HMEC. All OxyBURST data is pre- positivity was 50%, which is likely to increase as more samples are looked at. sented as mean percentage area fluorescence per cell ± S.E.M. wild-type Conclusion: Respiratory viruses are readily detected in exhaled breath using MLEC infected with IAV had increased endosomal ROS compared to unin- our methodology and the concordance with BAL samples suggests that the fected cells (0.88 ± 0.13, 0.56 ± 0.06, respectively, p=0.02, n=6), that was re- exhaled breath technique reflects the presence of viruses in the lower respira- duced in Nox2-/- MLEC (0.17 ± 0.04, p<0.0001, n=6). There was increased tory tract. The detection of some viruses only in filters and not BAL means we endosomal ROS in poly I:C-treated wild-type MLEC compared to the control may also be detecting upper respiratory tract viruses. The methodology is sim- (1.28 ± 0.25, 0.64 ± 0.16, respectively, p=0.02, n=8), that was reduced in ple, inexpensive and much less invasive than BAL and holds great promise for Nox2-/- MLEC (0.36 ± 0.08, p=0.001, n=8). longitudinal and community based studies of the impact of respiratory viruses. Conclusion: This study shows for the first time that IAV internalised into endothelial cells via endocytosis, and causes a Nox2 dependent increase in endosomal ROS, potentially by a TLR3-mediated mechanism. Targeting this pathway could be the key to treating millions of seriously ill patients. Grant Support: Australian Research Council and NHMRC.

TO 122 Interventional Pulmonary/Bronchology 2 Oral Presentations CT DETECTION OF VISIBLE ENDOBRONCHIAL ANATOMICAL VARIANTS WITH THE KURIMOTO CT BRONCHIAL BRANCH READING METHOD SHOWS HIGH SPECIFICITY TO 121 FIELDING D1,GALTL1, PAHOFF C1, RITCHIE A1, HUNDLOE J1, BASHIRZADEH F1,KURIMOTON2 1 2 A NEW BRONCHOSCOPY TEACHING TOOL (A HIGH Royal Brisbane and Womens Hospital, Santa Marianna University School of DEFINITION LAP TOP BASED SIMULATOR—THE CIRCULAR Medicine, Tokyo, Japan. CHECKLIST) SHOWS TRAINING BENEFIT IN A CROSS OVER EVALUATION Introduction/Aim: Interpreting variations at bronchoscopy can be difficult but can be clinically very important. The Kurimoto method describes how a FIELDING D1, BASHIRZADEH F1, COLES T2,DUMASC2, SALVADO O2 conventional fine cut CT scan can be rotated to allow viewing of bronchial 1Royal Brisbane and Womens Hospital, 2Australian e-Health Research openings on CT in an orientation which mimics the endobronchial appear- Centre, UQ Health Science Building, Royal Brisbane and Women’s Hospital, ance. For example, in viewing the left upper lobe, the CT is rotated 90° clock- Herston, QLD, Australia wise. In this study, we pilot the use of this method to detect third-order bronchial variations. Methods: From a cohort of 160 cases from another study, 10 representa- Introduction/Aim: Simulated training is fundamental for all trainees tive cases were selected for each of the right upper and lower and left upper starting bronchoscopy training. Access to simulators can be difficult and and lower lobes. Each case had a confirmed third-order bronchus appearance costly. A new high definition laptop based training tool (The Circular Checklist, from video assessment. CTs for each case were rotated as per the Kurimoto CCL) has been developed. It simulates the experience of moving around the method and reported by five experienced bronchoscopists; each lobe was bronchial tree in a sequential fashion using the Boyden classification of bron- scored using Kitamura’s atlas. Readers were blinded to the bronchoscopic chial naming. Subjects must sequentially name and move into bronchial open- appearance. Results were reported in groups of variants which reflect clinical ings before moving on to the next bronchus, starting at B1 and finishing at B10 groupings. on each side. Results: The distribution of normal to abnormal variants in each of the Methods: At a bronchoscopy training school, a prospective study was con- group of 10 scans was seven and three, except in the left lower lobe when it ducted with informed consent of participants. Trainees who had bronchoscopy was six and four. experience were new to the Boyden classification, which were divided into two groups after stratification based on anatomy knowledge. After a bronchoscopic anatomy lecture, Group 1 was given 1 h to train on the CCL, completing RUL RLL LUL LLL all tasks and then assessed on a low fidelity bronchoscopy model with a real bronchoscope, using the Bronchoscopy Skills and Tasks Assessment Tool (B STAT). Group 2 had no such training but had the BSAT. BSTAT tests at each Normal no. Normal no. point were done in duplicate with the second test reported. Then there was a Groupings of Trifurcation vs Bifurcation vs cross over with Group 2 having CCL training and both groups had repeat normal vs vs non- additional vs additional BSTAT. Maximum score on BSTAT is 42. Abn.variants trifurcation bronchi trifurcation bronchi Results: Nineteen subjects completed the CCL training and did both sets of assessment. Group 2 showed a significant learning gain. Group 1 results Sensitivity, 73% 83% 60% 100 were on the whole better after their first CCL training. Subjects found the CI (48–89) (61–94) (36–80) (84–100) CCL easy to use and had high satisfaction from the training. Speciﬁcity, 80% 83% 83% 77 CI (64–90) (69–92) (67–92) (59–88) BSTAT results (Mean, SD)

Test 1 Test 2 Conclusion: Overall, specificity was high and the sensitivity data for the lower lobes show promise for the potential of the method in predicting the 31.1 ± 6.5P =0.3,NS Group 1 (CCL training 32.9 ± 9.8 presence of variations there. This study has not analysed the ability to state before BSTAT test 1) which of the abnormal variants is present, but merely recognizing the pres- Group 2 (CCL training 20.7 ± 14.1 27.7 ± 9.3P =0.019 ence of a variant could lead to detailed CT examination before the procedure. after BSTAT Test 1) Reference. Kurimoto N. CT Branch reading method for bronchoscopy. Japan. Igaku Shoin 2015. Conclusion: The CCL assists in bronchoscopic anatomy learning and Grant Support: Nil. sequential bronchial navigation. Grant Support: Nil. Conflict of Interest: Authors 3 and 4 are involved with Sollertia Medical which is developing this software.

TO 123 TO 124

GRANULOMATOUS INFLAMMATION FOUND BY SAFETY AND EFFICACY OF RADIAL ENDOBRONCHIAL ENDOBRONCHIAL ULTRASOUND TRANSBRONCHIAL ULTRASOUND (R-EBUS) FOR THE INVESTIGATION OF NEEDLE ASPIRATION (EBUS-TBNA) IN PATIENTS WITH SOLITARY PULMONARY NODULE IN PATIENTS WITH MALIGNANCY—A QUATERNARY REFERRAL CENTRE ADVANCED COPD EXPERIENCE GEORGIOU H, TAVERNER J, IRVING L, STEINFORT D FON A1, BAUMANN A2,JERSMANNH1,ROBINSONP1,NGUYENP1 Royal Melbourne Hospital 1The Department of Thoracic Medicine, Royal Adelaide Hospital, 2The Department of Internal Medicine Services, Royal Adelaide Hospital Introduction/Aim: Solitary pulmonary nodule (SPN) is a common scenario in patients with COPD and represents a high risk of malignancy. Radial Introduction/Aim: Endobronchial ultrasound transbronchial needle aspi- endobronchial ultrasounds (R-EBUS) with transbronchial lung biopsy (TBLB) ration (EBUS-TBNA) is a commonly used technique to investigate suspicious is the preferred first line diagnostic test for peripheral SPN. To date, no study mediastinal and/or hilar lymphadenopathy in patients who have a history of has assessed outcomes of R-EBUS in patients with COPD. We sought to as- cancer. The finding of granulomatous inflammation during this routine proce- sess the safety and efficacy of R-EBUS for the evaluation of SPN in patients dure currently has unknown clinical implications. This study aimed to review with advanced COPD. the incidence of lymphadenopathy due to granulomatous inflammation in pa- Method: Advanced COPD was defined as severe and very severe obstruc- tients with a concurrent diagnosis of cancer at our centre and compare this to tive deficit on spirometry (FEV1/FVC ratio < 0.7 and FEV1 ≤ 50%predicted) previous published cohorts. and/or severe impairment in diffusion capacity (DLCO ≤ 50%). Outcomes for Methods: A retrospective, single-centre observational study was per- all patients with advanced COPD undergoing R-EBUS for the evaluation of formed. All EBUS-TBNA cases from July 2009 to June 2015 inclusive were SPN at the Royal Melbourne Hospital from January 2012 to September reviewed along with accompanying pathology results, case records and med- 2015 were evaluated to determine rate of complications and diagnostic yield ical correspondence. All patients with cytological or histological evidence of and sensitivity. granulomatous lymphadenopathy (necrotizing and non-necrotizing) were Results: During the study period, 88 patients underwent 90 procedures assessed for a concurrent diagnosis of malignancy or a new diagnosis of ma- with a mean age of 70.0 ± 9.8 years (SD) and mean lesion size 25.7 mm lignancy during follow up. (range 7–105 mm). Forty-seven patients had severe obstructive deficit with Results: A total of 788 EBUS-TBNA procedures were done during the a mean FEV1 of 1.02 ± 0.28 L (SD), predicted FEV1 40.0 ± 8.2% (SD) and study period. Cytological or histological evidence of granulomatous inflamma- DLCO 49.8 ± 15.5% (SD). Forty-one patients had mild–moderate obstruction tion was confirmed in 135/788 (17%). Once confirmed cases of tuberculosis with severe diffusion impairment and a mean DLCO of 41.4 ± 7.9% (SD), were excluded, a total of 23/135 (17%) cases also had a concurrent diagnosis FEV1 1.73 ± 0.55 L (SD) and predicted FEV1 71.6 ± 13.4% (SD). The rate of cancer or a new diagnosis of cancer during follow-up. The remaining cases of pneumothorax was 2.2% (95%CI: 0.1–8.2%), need for intercostal catheter are being followed up as sarcoidosis. insertion 1.1% (95%CI 0.0–6.6%), rate of admission to hospital 11.1% (95% Conclusions: Lymphadenopathy in patients with a history of cancer can- CI 6.0–19.4%), with eight patients (80%) discharged within 24 h. There were not always be attributed to malignancy, and needle aspiration is paramount no deaths, no cases of pulmonary haemorrhage and no patients required so that patients are not denied curative treatment for the primary disease. pleurodesis. The diagnostic yield was 64.4% (58/90) and overall sensitivity Conversely, granulomatous inflammation, in the absence of an attributable for primary lung malignancy 70.8–78.5%. Yield and sensitivity were signifi- cause such as tuberculosis may be a risk factor for the development of a ma- cantly influenced by target lesion size. lignancy. The clinical implication is unclear and poses new areas for further re- Conclusion: R-EBUS is a safe and effective procedure for the investiga- search and investigation. tion of peripheral solitary pulmonary nodule in patients with advanced COPD. Grant Support: Nil. Grant Support: Nil.

TO 125 TO 126

CRYO-BIOPSY GIVES BETTER SAMPLES IN COMPARISON TO OPTIMIZING SAMPLE HANDLING IMPROVES DIAGNOSTIC CONVENTIONAL RADIAL EBUS SAMPLING, IN DIAGNOSING YIELD IN ENDOBRONCHIAL ULTRASOUND GUIDED PERIPHERAL PULMONARY LESIONS BIOPSIES IN MALIGNANT NODES

Descriptive case series from cryo-biopsy feasibility and CT-CROP studies NEWHOUSE S1, KLEBE S2,3,KRUGERA2,MOFFATD2,ROSEA1,3, HERATH S1,YAPE1, LOW I2 D’COSTA J1,3 1Department of Respiratory Medicine, Middlemore Hospital, Auckland, New 1Respiratory Medicine and Sleep Services, Flinders Medical Centre, Zealand, 2Department of Pathology, Middlemore Hospital, Auckland, New Adelaide, SA, 2Department of Cytology and Anatomical Pathology, SA Pathol- Zealand1 ogy, Adelaide, SA, 3Flinders University School of Medicine, Adelaide, SA

Introduction/Aim: Despite the better safety profile, the yield of radial Introduction/Aim: Endobronchial ultrasound (EBUS) transbronchial needle endobronchial ultra sound (R-EBUS) remains lower (73%) than CT-guided bi- aspiration (TBNA) is an established technique for sampling of hilar and medias- opsy (90%) in diagnosing peripheral pulmonary lesions (PPL). We performed tinal lymph nodes. Rapid on-site cytological evaluation (ROSE) has been sug- cryo-biopsy via the R-EBUS Guide Sheath (GS) in an attempt to produce gested to improve diagnostic accuracy and reduce the number of passes per larger, non-crushed samples to improve the diagnostic yield. node; however, methods to refine EBUS sample handling to improve diagnostic Methods: All patients who had a PPL and undergone a combined R- yield are currently poorly defined. This study aims to determine if ROSE EBUS/cryo-biopsy procedure were prospectively included. Samples were ob- improves diagnostic accuracy of EBUS-TBNA in our institution and whether tained via needle aspiration, forceps and brush, followed by cryo-biopsy using sample processing improves diagnostic yield. The second aim was to determine the GS. Up to three cryo-biopsies were obtained, at 4-s application with pro- the contribution of the cell block compared with the slides for diagnostic value. phylactic placement of an endobronchial blocker. A CXR was performed 1-h Methods: A retrospective audit was conducted on all linear EBUS-TBNA post-procedure. procedures performed between 2 February 2015 and 20 August 2015 inclu- Results: Out of the six patients, four were females (67%) with a mean age sive performed for all indications and was divided into those with and without of 56 years (42–76 years). Five PPL’s were in upper lobes. The maximal ROSE. A prospective audit began 21 August 2015 and included linear EBUS mean lesion diameter was 4.1 cm (1.9–6.6 cm). All the PPL’s were visualized procedures with and without ROSE with the clinical suspicion of malignancy with R-EBUS. with standardization of sample collection, handling and reporting between The mean size of a cryo-biopsy was twice the size of forceps biopsy (Cryo-bi- the two groups. Statistical analysis was performed using Fisher’s exact test. opsy 6.4 mm (5–8 mm): vs. forceps biopsy 3.4 mm (1–5mm)). Results: Retrospective data from February to August 2015 demonstrated Five out of the six (83%) patients were diagnosed with a malignancy (Table 1). a significant difference in diagnostic rates between procedures with ROSE Four patients had positive samples from both cryo-biopsy and R-EBUS. In all (n = 17/18, 94.4%) compared with those without ROSE (n = 17/26, 65.4%) four patients, cryo-biopsy samples were superior in the size of the sample, and [p = 0.0311]. Needle size and sedation method did not alter diagnostic yield the number of malignant cells/hpf and was the preferred sample chosen for in either group. Interestingly, there was a trend towards improved diagnostic mutation analysis. accuracy without ROSE when increased numbers of nodes were sampled One (Patient 1) would have required a repeat procedure to enable complex or when three or more passes were performed per node, although numbers immunohistochemistry analysis had the patient not undergone cryo-biopsy are small. In the prospective ROSE group (n = 4/4, 100%) and the non-ROSE (Table 1).There was no pneumothorax or bleeding. group (n = 11/12, 91.6%), with data collection ongoing, there were improved Conclusions: Our preliminary results suggest cryo-biopsy samples to be diagnostic rates. The cell block provided added diagnostic information includ- consistently larger and was the preferred sample for EGFR analysis in com- ing immunohistochemical profiling and material for molecular analysis. parison to conventional R-EBUS sampling, with an increase in the diagnostic Conclusion: This study suggests that ROSE is an important requirement for yield and reduction in the need for repeat procedures, without compromising increased diagnostic yield in EBUS-TBNA; however, this difference may be over- safety. come by standardizing sampling methods, sample handling and processing. Grant Support: Koawetea seed fund, Middlemore Hospital, New Zealand Grant Support: No grants supported this project. Ethics approval #235.15. and Asser trust equipment fund, Auckland, New Zealand. Conflict of Interest: None to declare.

This table relates to abstract TO 125

Table 1. Characteristics of radial EBUS and cryo-biopsy samples, demonstrating cryo biopsy to be the preferred sample for mutation analysisCharacteristics of radial EBUS and cryo-biopsy samples, demonstrating cryo biopsy to be the preferred sample for mutation analysis

Radial EBUS sampling

PPL Size Needle Preferred sample Final Index Sex/Age Sedation (cm) Location aspiration Brush Forceps Cryobiopsy for EGFR analysis diagnosis

1 F-54 CS 3.88 LUL Neg Pos Neg Pos 8 mm Cryo Large cell, high grade 1mm neuroendocrine 2 F-47 CS 4 RML Pos Pos Pos Pos 6 mm Cryo Adenocarcinoma 5mm 3F-76CS5.3LLLPosPosNegPos 6 mm Cryo Squamous cell 2mm carcinoma 4 M-52 CS 3 RUL Pos Pos Pos Pos 7 mm Cryo Adenocarcinoma 5mm 5 F-42 CS 1.9 LUL Neg Neg Not Neg 5 mm Surgery Hamartoma(surgical done resection) 6M-69GA6.6LULPosPosNegError in Radial brush Adenocarcinoma 4mm measurement

TO 128 Physiology and Sleep 2 Oral Presentations

THE CARDIOVASCULAR RESPONSE TO OBSTRUCTIVE SLEEP APNOEA IS REDUCED IN OLDER INDIVIDUALS TO 127 Stanghi J1,TurtonA2,HamiltonG2,3,O’Driscoll D1,3 1Department of Respiratory and Sleep Medicine, Eastern Health, VIC, Austra- lia, 2Monash Lung and Sleep, Monash Health, VIC, Australia, 3Department of VENTILATION HETEROGENEITY EARLY POST-LUNG Medicine, School of Clinical Sciences, Monash University, VIC, Australia TRANSPLANT PREDICT REJECTION AND MORTALITY Introduction/Aim: Large population-based studies suggest that the car- THOMPSON B1, ELLIS M2, VERBANCK S3,KOTSIMBOST4, LIAKAKOS diovascular risk arising from obstructive sleep apnoea (OSA) is not uniform P5, SNELL G6 across the population, with the elderly potentially being spared OSA-associ- 1The Alfred Hospital, Monash University, 2The Alfred Hospital, Monash ated cardiovascular morbidity. The aim of this study was to test the hypothesis University, 3University Hospital UZ Brussel, 4The Alfred Hospital, Monash that the heart rate (HR) response post-apnoea is reduced in older individuals University, 5The Alfred Hospital, Monash University, 6The Alfred Hospital, compared with younger individuals. Monash University Methods: Eighteen patients with moderate/severe OSA (apnoea/ hypopnoea index [AHI] > 15 events/h) but otherwise healthy, were recruited Introduction/Aim: We have previously demonstrated that there is signifi- from a clinical cohort attending for polysomnography. Data were stratified by cant ventilation heterogeneity in the very peripheral compartment of the lung age (split at 50 years. Y = younger, 35.7 ± 3.3 years, n = 7. O = older, 60.4 < that follows the progression of airflow obstruction associated with BOS (1). ± 1.9 years, n =11. p 0.001). Respiratory events in stage N2 sleep were What is not clear is the ability of conductive (Scond) and acinar (Sacin) venti- identified, and beat-by beat HR was averaged for pre-event, early-event, lation heterogeneity to predict rejection or mortality post lung transplant. late-event and post-event. Variables were compared between groups using Methods: Thirty-three consecutive bilateral sequential lung transplant re- unpaired t-tests. Multivariate cluster-wise linear regression was used to deter- cipients were recruited and studied for 4 years post-lung transplant. Regular mine independent predictors of % change in HR from late to post-event. assessments of lung function including multiple breath washout using nitrogen Results: There was no difference between groups for gender, body mass (MBNW) were performed. index, AHI, systolic or diastolic blood pressure, or smoking status. However, Results: Of the 33 patients, 19 developed BOS within 4 years post-trans- the younger group scored higher on the Epworth Sleepiness Scale (Y: 11 < plant, and eight of these patients died during the study period. A ±1,O:6±1,[SEM]p 0.05). The mean acute %change in HR post-event À Scond > 0.035 L 1 measured within 6 months post-lung transplant had signif- was significantly reduced in the older group compared with the younger group < icant risk of BOS/Death within 4 years. The hazard ratio for Scond to predict (Y: 19.0 ± 2.0%, O: 12.2 ± 1.4%, p 0.05). Stepwise multivariate clusterwise β death was 4.14 (95% confidence interval 1.31–13.02 p = 0.0032). Sacin and regression revealed that younger age ( = 0.44) and length of arousal β spirometric measures were unable to predict BOS/ Death. However, similar ( = 0.25) were significant independent predictors of a larger %change in HR 2 < to our previous studies Sacin was significantly related to FEV1/FVC ratio post-event (Model R =0.21,p 0.05), whilst event type, event duration and (r2 = À0.636, p < 0.0001). oxygen desaturation were not. Conclusion: These data indicate that the acute HR response to obstructive apnoea is dampened with ageing. We speculate the reduced cardiovascular response post-apnoea may be protective against the link between sleep apnoea and hypertension in older individuals. Grant Support: Lung Foundation Australia/Ludwig Engel Grant-in-Aid for Physiological Research.

Conclusion: Elevated Scond 6 months post-lung transplantation is associated with greatly increased risk of BOS or mortality within 4 years. 1. Thompson BR et al. Bronchiolitis Obliterans Syndrome leads to a functional deterioration of the acinus post lung transplant. Thorax. 2014;69:488–489. Grant Support: NHRMC.

TO 129 TO 130

INCREASING CEREBRAL BLOOD FLOW REDUCED CENTRAL RIGHT HEART FUNCTION AND GAS EXCHANGE DURING SLEEP APNOEA SEVERITY AT HIGH ALTITUDE SIMULATED ALTITUDE IN PULMONARY ARTERIAL HYPERTENSION BURGESS K1,2,LUCASS3,4,BURGESSK1,2,SPRECHERK1,DONNELLY J3,5,BASNETA6,AINSLIEP7 SECCOMBE L1,2,CHOWV2,3,ROGERSP1,BUDDLEL1,ZHAOW3,PE- 1Peninsula Sleep Clinic. Sydney, Australia, 2University of Sydney. Sydney, TERS M1,2,NGA2,3,VEITCHE1, KRITHARIDES L2,3 Australia, 3University of Otago. Dunedin, New Zealand, 4University of Birming- 1Thoracic Medicine, Concord Hospital, 2Sydney Medical School, Sydney ham, Birmingham, UK, 5Good Samaritan Hospital, Phoenix, USA University, 3Cardiology, Concord Hospital

Introduction: Exposure to very high altitudes causes central sleep apnoea Introduction/Aim: Pre-existing pulmonary arterial hypertension (PAH) at (CSA). We have previously shown that increasing cerebral blood flow (CBF) sea level may increase the risk of medical complications at mild altitude equiv- by iv acetazolamide (AZ) reduced CSA severity by ~50%; however, this effect alent to commercial aircraft flight. Patients with PAH may be limited by right was confounded by a rise in PaCO2 of ~3 mmHg. Aim: Our aim is to study the heart function; however, its relationship to arterial oxygenation during mild effects of increasing CBF on CSA without altering PaCO2. hypoxia is unknown. We investigated the effect of simulated 2400 m altitude Methods: At 5050 m (The Pyramid, Lobuje, Nepal), 11 subjects (eight at rest and during mild exercise on measures of pulmonary hemodynamics, males and three females; aged 31 ± 7 years) completed awake ventilatory re- right heart function and gas exchange in patients with PAH and compared to sponse testing pre- and post-injection of either iv AZ (10 mg/kg) combined with healthy normals. dobutamine (DB) (2-5 ug/kg/min) or placebo injections/i.v (order randomized). Method: PAH and healthy subjects were recruited. Gas exchange was Immediately following pharmacological/placebo, CBF measurements and monitored continuously while at rest breathing room air and while breath- ventilatory response testing were made, and subjects underwent full ing15%O2, at rest for 20 min and during mild exercise. Echocardiography polysomnography monitored sleep, while the pharmacological (DB) interven- and exertion scales (BORG) were performed at each stage. Stages were tion was maintained. Arterial blood gas samples were collected and ventilatory assessed using a two-way ANOVA, parameter associations via Pearson’s responses to hypercapnia (HCVR) and hypoxia (HVR) were measured. Du- correlation and group comparisons by unpaired t-tests. plex ultrasound of volumetric blood flow in the internal carotid and vertebral ar- Results: Nine Group 1 PAH (mean (SD) age 65 (12) years) and seven teries was used to estimate global CBF. healthy subjects (51 (15) years, P = 0.05) were studied. Pulmonary arterial Results: Iv AZ/DB increased global CBF by 34% compared to placebo systolic pressure (PASP) increased in both groups during hypoxia, both at rest (P < 0.001). HCVR declined from 5.9 ± 2.7 to 4.2 ± 2.8 L/min/mmHg (mean and with exercise (P < 0.03) and were highly predictive from room air PASP ±SD) (P = 0.066). CSA index fell from 140 ± 45 to 48 ± 11 (mean ± SD) (R2 =0.9, P < 0.001). Pulmonary vascular resistance (PVR) was higher in events per hour of sleep (P < 0.001). HVR and PaCO2 were unchanged. PAHcomparedtonormal(P < 0.001) but did not change during hypoxia. Conclusion: Pharmacologically increasing CBF without alteration of Gas exchange responses were not different between groups. PaCO2 markedly reduced the severity of central sleep apnoea at high altitude, Room air PaO2 did not correlate with PASP at any stage (P = 0.1); however, possibly by reducing HCVR. during hypoxia at rest, PaO2 correlated with PASP (R2 =0.7, P < 0.04). Supported by Peninsula Health Care Pty Ltd, NSERC, CRC and Lottery Health NZ. BORG increased in PAH subjects only (P < 0.02). No adverse events were Research conducted under the memorandum between Nepal Health evident, and the protocol was tolerated well. Research Council and EVK2-CNR. Conclusion: In patients with PAH, PASP at simulated mild altitude, both at rest and during mild exercise, can be predicted from room air values. The increase in PASP was not associated with deterioration in right heart function, a change in PVR nor the extent of desaturation, but appears attributable to increased cardiac output. Key words: altitude simulation, hypoxia, pulmonary arterial hypertension, pulmonary vascular resistance Grant Support: Nil.

TO 131 TO 132

INCREASED DEAD SPACE VENTILATION MEDIATES EXERCISE CARDIAC MAGNETIC RESONANCE IMAGING: A REDUCED EXERCISE CAPACITY IN SYSTOLIC HEART NOVEL TECHNIQUE FOR ASSESSING RIGHT VENTRICULAR FAILURE CONTRACTILE RESERVE.

KEE K1,2, STUART-ANDREWS C1, ELLIS M1,WROBELJ1,2,NILSENK1,2, TROY L1,2,ARNOTTC2,3,CORTET1,2,MUNOZP1,2, LAOHACHAI K2,4, SHARMA M1, THOMPSON B1,2,NAUGHTONM1,2 LACKEY H5,LAUE1,2,TORZILLOP1,2,CORTEP1,2,CELERMAJERD2,3, 1Department of Allergy, Immunology and Respiratory Medicine, The Alfred, PURANIK R2,3 2Department of Medicine, Monash University 1Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, 2Sydney Medical School, University of Sydney, 3Department of Cardiology, 4 Introduction/Aim: Chronic heart failure (HF) patients have limited exercise Royal Prince Alfred Hospital, Department of Paediatric Cardiology, 5 capacity which cannot be completely explained by markers of cardiac dys- Westmead Childrens Hospital, Specialist Magnetic Resonance Imaging function. Reduced pulmonary diffusing capacity at rest and excessively high ventilation during exercise are common in HF. We hypothesized that the Aim: The impact of pulmonary disease on the structure and function of the reduced pulmonary diffusing capacity in HF patients would predict greater right ventricle (RV) is not well elucidated. Current modalities for imaging the dead space ventilation during exercise and that this would lead to impairment RV provide limited information. Real-time cardiac magnetic resonance in exercise capacity. We sought to determine the relationship between pulmo- (CMR) imaging is an emerging technique for detailed assessment of cardiac nary diffusing capacity at rest and dead space ventilation during exercise and chamber size and function. As a proof of concept, we aimed to specifically to examine the influence of dead space ventilation on exercise in HF. evaluate the augmentation of RV ejection fraction (EF) during the increasing Methods: We analysed detailed cardiac and pulmonary data at rest and external workload applied during exercise CMR. during maximal incremental cardiopulmonary exercise testing from 87 con- Methods: Subjects underwent incremental cardiopulmonary exercise test- secutive heart transplant assessment patients and 18 healthy controls. Dead ing to determine maximal oxygen uptake (VO2max) and work-rate (Wmax). space ventilation was calculated using the Bohr equation. On a separate day, real-time CMR was performed at rest and during incre- Results: Pulmonary diffusing capacity at rest was a significant predictor of mental exercise; [Protocol included two workload stages: 30% Wmax (stage dead space ventilation at maximal exercise (r = À0.524, p < 0.001) in HF but 1) and 60% Wmax (stage 2)], using a specialized ergometer. Images were ac- not in controls. Dead space at maximal exercise also correlated inversely with quired during free-breathing and breath-holding maneouvres. Aortic and pul- peak oxygen consumption (r = À0.598, p < 0.001), peak oxygen consumption monary artery flows, and RV and LV end-diastolic and end-systolic volumes per kilogramme (r = À0.474, p < 0.001) and 6 min walk distance (r = À0.317, were measured at each stage to calculate RVEF and LVEF. p = 0.021) in the HF group but not in controls. Results: Four healthy volunteers (two males, mean age 49.5 ± 9.3 years, Conclusions: Low resting pulmonary diffusing capacity in HF is associated BMI 25.8 ± 3.0 kg/m2) completed the pre-specified protocol. At CPET, mean with high dead space ventilation during exercise, leading to excessive and in- VO2max was 132 ± 12.0% predicted and Wmax was 136.8 ± 16.9% pre- efficient ventilation. These findings would support the concept of pulmonary dicted. At exercise CMR, the measured LVEF and RVEF significantly aug- vasculopathy leading to altered ventilation perfusion matching (increased mented with increasing workload. The resting mean LVEF was 65.3 ± 8.0% dead space) and resultant dyspnoea, independent of markers of cardiac and RVEF was 54.8 ± 1.9%, increasing to 72.3 ± 7.4% (p = 0.02), and 62.5 function. ± 4.7%, (p = 0.02), respectively. At stage 2, there was further rise in LVEF Grant Support: Australian Post-Graduate Foundation, Alfred Research and RVEF: 80.0 ± 6.7, (p < 0.001) and 74.5 ± 2.1, (p < 0.001), respectively. Trust. Aortic and pulmonary flows augmented accordingly at each stage of exercise. Conclusions: Real-time CMR is a feasible and novel non-invasive test for measuring both right and left ventricular contractile reserve during incremental sub-maximal exercise. This technique may be utilized to evaluate the response of the RV during conditions of stress in patients with pulmonary disease.

TO 134 OLIV 2 Oral Presentations

DIAGNOSTIC ACCURACY AND CONCORDANCE OF DIFFERENT CRITERIA FOR EXERCISE PULMONARY HYPERTENSION TO 133 LAU E1, GODINAS L2,MONTANID3,4,5,SAVALEL3,4,5, SITBON O3,4,5, HUMBERT M3,4,5,CHEMLAD3,5,HERVEP6 SMAD SIGNALLING PROFILES ARE ALTERED FOLLOWING 1Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, BMPR2 AUGMENTED EPC DELIVERY IN A RAT Australia, 2CHU Mont-Godinne, Université Catholique de Louvain, Yvoir, MONOCROTALINE INDUCED PAH MODEL Belgium, 3Univ. Paris-Sud, Le Kremlin-Bicêtre, France, 4AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire Sévère, 1 1 2 1 Le Kremlin-Bicetre, France, 5INSERM UMR_S999, LabEx LERMIT, Centre HARPER R ,WARDR,BONDERC, REYNOLDS P 6 1Lung Research Laboratory, 2Centre for Cancer Biology Chirurgical Marie Lannelongue, Le Plessis Robinson, France, Departement de Chirurgie Thoracique, Vasculaire et de Transplantation Pulmonaire, Introduction/Aim: PAH is a rare but devastating lung disease with survival Hopital Marie Lannelongue, Le Plessis Robinson, France of 55% at 3 years. Reduced expression of the bone morphogenetic protein receptor type-2 (BMPR2) is causally linked to PAH. Previously, we transduced Introduction/Aim: A refined definition of exercise pulmonary hypertension > rat endothelial progenitor cells (EPCs) with AdBMPR2 and transplanted them (PH) combining mean pulmonary artery pressure (mPAP) 30 mmHg and > into rats with monocrotaline (MCT) induced PAH. The PAH was subsequently total pulmonary vascular resistance (TPVR) 3 WU has been shown to attenuated. Here, we assessed the bio-distribution of transplanted cells and significantly improve diagnostic accuracy compared to the old abandoned > 1 BMPR2 mediated Smad signalling. criteria of mPAP 30 mmHg. Recently, other refined definitions of exercise Methods: Bio-distribution: Bone marrow cells (BMCs) were extracted from PH have been proposed in the literature. Our aim was to compare the perfor- the femur of donor rats and cultured in selective endothelial medium. After mance and concordance of these refined definitions for exercise PH. ≤ 6 days, cells were characterized and cells transduced with AdTrackLuc were Methods: This study included 169 patients with resting mPAP 20 mmHg injected (IV) at 5 × 106 cells/rat and imaged on a BioPhotonic Imager (Lumina IVIS). who underwent invasive exercise testing. Patients were stratified a priori into MCT model: Ten days following MCT treatment, rats were intravenously (1) controls with no heart or lung disease (n = 68), pulmonary vascular disease injected with EPCs only, AdBMPR2 + EPCs, or un-injected. After a further (PVD) (n = 49) and left heart disease (LHD) (n = 52). The following criteria 8–10 days, PAH was assessed. Lungs analysed for Smad protein via were assessed for diagnostic accuracy and concordance: (1) peak mPAP > immunoblot. 30 mmHg (mPAPmax) + peak total pulmonary vascular resistance > EPC studies: Healthy rats (n=3) were injected with AdBMPR2 transduced (TPVRmax) 3 WU, (2) slope of multipoint mPAP-cardiac output relationship > EPCs and sacrificed an hour later. Lungs were processed and analysed as (mPAP-COslope) 3 WU and (3) ratio of peak mPAP minus resting mPAP Δ Δ > above. divided by the peak CO minus rest CO ( mPAP/ CO) 3WU. Results: Bio-distribution studies: Imaged animals (n = 4) showed strong Results: All three criteria were associated with high diagnostic accuracy for positive luminescence (2.47 × 108 photons/s) across both lung lobes. Lungs the discrimination of controls from patients with PVD and LHD, with respective ex vivo had 5.757 × 108 photons/s, while the liver had only background signal. ROC area under the curve (AUC) as follows: mPAPmax + TPVRmax = 0.99, Δ Δ Smad signalling analysis: Rats (n=6) given EPCs + BMPR2 had a 2.3-fold mPAP-COslope = 0.94 and mPAP/ CO = 0.96. When the three criteria with increase in Smad1/5/8 activation and 1.7-fold decrease in activated Smad3 their respective cut-off values were used to classify patients into the presence compared to MCT Only, 10 days post-BMPR2 treatment. Additionally, lungs or absence of exercise PH, concordant classification was found in 80.5% of from healthy rats treated with EPCs + BMPR2 (n = 3), had a 1.2-fold increase cases for mPAPmax + TPVRmax versus mPAP-COslope (kappa = 0.61), Δ Δ in activated Smad1/5/8 compared to untreated healthy rats and 4.6-fold 85.8% for mPAP + TPVR versus mPAP/ CO (kappa = 0.71) and 84.0% for Δ Δ increase compared to MCT treated rats (p = 0.05). mPAP-COslope versus mPAP/ CO (kappa = 0.68). > Conclusions: BMPR2 mediated Smad signalling is altered following Conclusions: The criteria of mPAPmax 30 mmHg and > BMPR2 transduced EPC transplant. The success of BMPR2 cell therapy is TPVRmax 3 WU has high diagnostic accuracy with the advantage of sim- due to the natural homing of these cells to the lungs, making these an ideal plicity and obviates the need for multipoint mPAP-CO calculations. Different candidate for pulmonary vascular therapy. criteria that have been recently proposed for exercise PH are not interchange- Grant Support: NHMRC, RAH Research Committee. able, with diagnostic disagreement found in up to 19.5% of cases. Conflict of interest:Nil. 1Herve P, Lau EM, Sitbon O et al. Eur Respir J 2015;46:728–37

TO 135 TO 136

SHORTENED ALLOGRAFT EPITHELIAL TELOMERE LENGTH—A PERCENTAGE PREDICTED IS NOT SUPERIOR TO ABSOLUTE LASTING LEGACY OF DONOR AGE AND SMOKING HISTORY SIX-MINUTE WALK DISTANCE AS A PREDICTOR OF MORTALITY IN PULMONARY HYPERTENSION YERKOVICH S1,2,TANM1,2,SAMSONL1,2, FIENE A1, HOPKINS P1,2, CHAMBERS D1,2 STANLEY C1, LAVENDER M1,5,MUSKM1,JARYC1, STRANGE G2,5, 1The Prince Charles Hospital, 2The University of Qld KEOGH A3,4,WROBELJ1,2,5 1Fiona Stanley Hospital, 2School of Medicine, University of Notre Dame, WA, 3 4 Introduction/Aim: Emerging evidence suggests that shorter telomere School of Medicine, University of New South Wales, NSW, Heart Transplant 5 length is a strong risk factor for pulmonary fibrosis. Telomeres protect against Unit, St Vincent’s Hospital, NSW, Pulmonary Hypertension Society of Austra- DNA damage during cellular replication, with telomere shortening leading to lia and New Zealand cellular senescence and impaired organ homeostasis. Given that chronic lung allograft dysfunction (CLAD) is associated with dysregulated epithelial repair Introduction/Aim: Absolute six-minute walk distance (6 MWD) and func- and subsequent fibrosis, we hypothesized that epithelial telomere length tional class have been validated as predictors of mortality in patients with would be important in the lung allograft. pulmonary arterial hypertension and form the basis of PBS (Pharmaceutical Methods: Airway epithelial cells were obtained from bronchial and bronchi- Benefits Scheme) funded prescription of pulmonary vasodilator therapies in olar brushings at post-transplant bronchoscopy or from healthy controls un- Australia. Several equations exist for predicting 6 MWD in adults from which dergoing bronchoscopy for chronic cough where no abnormalities were percentage predicted 6 MWD can be calculated. found. Average epithelial telomere length was measured by multiplexed We sought to determine whether percentage predicted 6 MWD was a better real-time PCR and the relative T/S telomere length calculated. Data are pre- predictor of mortality than absolute 6 MWD in patients with pulmonary hyper- sented as median (interquartile range). tension (all WHO groups). Secondary analysis included the impact of baseline Results: Airway epithelial cells were obtained on 203 occasions in 109 WHO functional class and patient demographics on mortality. patients (53% male, 50 (33–57) years at transplant, 37% CF, 35% COPD, Methods: Analysis was conducted from registry data of the Pulmonary Hy- 15% IPF and 95% bilateral). The median time of sampling was 12 (4–26) pertension Society of Australia and New Zealand (PHSANZ) which includes months post-transplant. The average bronchial and bronchiolar telomere patients with pulmonary hypertension from all five WHO groups. Inclusion length was 1.53 (1.28–1.69) and 1.46 (1.27–1.72), respectively. This telomere criteria were age at diagnosis > 18 years, diagnosis from 2004 and baseline length was similar to that seen in healthy adults (corrected for age, n = 10, age 6 MWD within 3 months of diagnostic right heart catheter. Baseline mortality 64 (46–75) years). Multivariate mixed-effects linear regression showed that predictors were taken at time of diagnosis. Percentage predicted 6 MWD both donor age and smoking history were associated with shorter bronchiolar was calculated using Chetta, Jenkins and Enright predictive equations. Sur- (β À0.009 (À0.014 to À0.005), p < 0.001, β À0.004 (À0.105–0.001), p = 0.09, vival analysis was performed using cox-proportional hazards model. respectively) and bronchial (β À0.009 (À0.013 to À0.005), p < 0.001, β Results: De-identified data for 2442 registry subjects were reviewed, of À0.010 (À0.211–0.012), p = 0.08, respectively) telomere length. which 923 subjects met the inclusion criteria. There were 285 deaths with Conclusions: The age and smoking history of the donor are forever an annual incidence rate of 9.2%. Mean 6 MWD was 308 +/À 136 m. Mean imprinted on the lung allograft through shorter telomere length, perhaps duration of follow-up from diagnosis was 3.33 +/À 2.42 years. Absolute explaining why older donor age is a risk factor for the development of CLAD 6 MWD, percentage predicted 6 MWD (all three equations), functional class in the recipient. and age at diagnosis were all significant predictors of mortality (p < 0.001) Grant Support: The Prince Charles Hospital Foundation. on univariate analysis. On multivariate analysis, only absolute 6 MWD (HR Declaration of Interest: None to declare. 0.997, 95% CI 0.995–0.998, p < 0.001), functional class (HR 1.965, 95% CI 1.509–2.557, p < 0.001) and age at diagnosis (HR 1.023, CI 1.014À1.032, p < 0.001) remained significant. Conclusion: Percentage predicted is not superior to absolute 6-min walk distance as a predictor of mortality in pulmonary hypertension. Grant Support: None.

TO 137 TO 138

MESENCHYMAL STROMAL CELLS ISOLATED FROM PULMONARY HYPERTENSION PATIENTS WITH BETTER GAS PULMONARY TRANSPLANT RECIPIENTS BY EXCHANGE DURING THE SIX MINUTE WALK TEST HAVE BRONCHOALVEOLAR LAVAGE ARE PROFIBROTIC LESS SEVERE DISEASE

SINCLAIR K1,2, YERKOVICH S1,2, HOPKINS P1,2,CHAMBERSD1,2 MORRIS N1, SEALE H2,HALLK2,HARRISJ2, LIN A2,KERMEENF2 1University of Queensland, School of Medicine, Queensland, Australia, 1Griffith University, 2The Prince Charles Hospital 2Queensland Lung Transplant Service, The Prince Charles Hospital, Queens- land, Australia Introduction/Aim: Alteration in gas exchange (GX) parameters including an elevated VE/VCO2̇ and a lower PETCO2 are well documented in pulmo- Introduction/Aim: Mesenchymal stromal cells (MSCs) are a stem-like nary hypertension (PH) and are strongly correlated with disease severity population of cells present within all post-natal tissues. While they have been and prognosis. PH patients with more severe disease also tend to increase isolated from bronchoalveolar lavage (A-MSCs) of lung transplant recipients, it their VE/VCO2̇ and decrease PETCO2 during exercise. The most common is unknown if these cells are distinct from the MSCs isolatable from normal pa- clinical test to assess exercise capacity in PH remains the six minute walk test renchymal lung tissue (T-MSCs). We hypothesized that A-MSCs would be (6 MWT) which does not conventionally include GX measurements. The aims dysregulated. The aim of this study was to compare A-MSCs and T-MSCs of this study were, in PH, to (1) describe the relationship between baseline to determine if they both fulfil the traditional criteria for MSC classification functional class (FC) and changes in GX measurements during 6 MWT and (CD105HighCD90HighCD73HighCD45Neg immunophenotype, tri-lineage differ- (2) compare patients with worse GX during 6 MWT (i.e. increased VE/VCO2̇ entiation potential) and to assess gene expression by microarray. and/or decreased PETCO2) to those with stable GX (i.e. either no change/de- Methods: MSC surface proteins (CD90, CD73, CD105 and CD45) and creased VE/VCO2̇ and no change/increased PETCO2). myofibroblast markers (collagen-1, vimentin and α-smooth muscle actin) were Methods: Ninety patients (49 ± 16 years) prospectively completed 6 MWT assessed by flow cytometry. Multipotency was assessed using inductive me- with simultaneous GX measurements using a portable metabolic cart (Cortex, dia. Transcriptional profiling was performed using the Illumina BeadChip v4.0 Metamax). Rest and peak-exercise GX measurements were determined from microarray. Data are expressed as median (inter-quartile range). 30 s averages. FC was determined by an independent physician before Results: T-MSCs and A-MSCs were CD90High,CD73High and CD45Neg.A- 6MWT. MSCs weakly expressed CD105 (mean fluorescent intensity (MFI) = 6.0, 4.3– Results: Sixty-five PH patients were FC I-II, and 25 were FC III. FC I-II 6.9, n = 15) compared to T-MSCs (MFI = 12.7, 12.2–14.8, n =6,p < 0.001). patients had significantly higher 6-min walk distance (6 MWD) (534 ± 79 Both populations differentiated into osteoblasts and chondroblasts; however, vs 399 ± 118 m, p < 0.05) and peak-exercise PETCO2 (28.2 ± 7.2 vs A-MSCs could not differentiate into adipocytes, indicated by failure to upregu- 24.7 ± 4.3 mmHg, p < 0.05) and lower peak-exercise VE/VCO2 (41 ± 10 late fatty acid binding protein-4 expression (2.6 fold increase, 1.09–35.6, vs 46 ± 10 mmHg, p < 0.05) compared to FC III. PH patients with worse n = 18) compared to T-MSCs (971 fold increase, 697.7–2034, n =6, `GX during 6 MWT (n = 53) had a significantly lower oxygen uptake p < 0.001). Transcriptional profiling identified 105 differentially expressed (0.91 ± 0.36 vs 1.07 ± 0.39, p < 0.05) and a higher FC (2.3 ± 0.5 vs 2.0 ± 0.5, genes, with the majority of those upregulated in A-MSCs and associated with p < 0.05) compared with those with stable GX. However, no significant fibroblast activation, TGFβ signalling and extracellular matrix deposition. A- difference was found between the two GX groups in their respective 6 MWD MSCs had increased expression of α-smooth muscle actin (MFI = 92.0, (p = 0.07). 76.0–124.1, n = 10 vs MFI = 55.7, 48.9–71.0, n =11,p < 0.05) and collagen- Conclusion: The addition of GX measurements to conventional 6 MWT 1(MFI = 4.6, 4.1–6.0, n =10vsMFI=3.6,3.1–4.0, n =11,p < 0.05). could provide incremental information on disease severity in PH patients Conclusions: A-MSCs and T-MSCs are distinct cellular populations. A- and potentially guide clinians in determining the adequacy of therapy. MSCs likely represent a population of cells undergoing fibroblast/ Grant Support: QH Health Practitioner Research Grant. myofibroblast differentiation. Future research will aim to determine if A-MSCs contribute directly to the invading fibroblasts observed in chronic lung allograft dysfunction. Grant Support: New Investigators Grant, The Prince Charles Hospital Foundation. Declarations of Interest: None.

TO 140 Asthma and Allergy 4 Oral Presentations

ETHNICITY AND AGE AT DIAGNOSIS PREDICT PREVENTER ADHERENCE IN CHILDREN WITH ASTHMA TO 139 CHAN A1,STEWARTA2,FOSTERJ3,MITCHELLE4, CAMARGO JR C5, HARRISON J1 1School of Pharmacy, Faculty of Medical and Health Sciences, The University THE LUNG MICROBIOTA IN STABLE ADULT ASTHMA of Auckland, Auckland, New Zealand, 2Epidemiology and Biostatistics, DIFFERS ACCORDING TO INFLAMMATORY PHENOTYPE School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand, 3Woolcock Institute of Med- 4 LEONG L 1,2, ROGERS G1,2, GIBSON P3,YANGI4,REYNOLDSP5, ical Research, University of Sydney, Australia, Department of Pediatrics: 5 6 5 7 7 Child and Youth Health, School of Medicine, Faculty of Medical and Health HODGE S , JAMES A , UPHAM J ,JENKINSC,PETERSM, 5 MARKS G8, BARAKET M8,SIMPSONJ3 Sciences, The University of Auckland, Auckland, New Zealand, Department 1Infection and Immunity theme, SAHMRI, Adelaide, SA, 2School of Medicine, of Emergency Medicine, Massachusetts General Hospital, Harvard Medical Flinders University, Bedford Park, SA, 3Centre for Asthma and Respiratory School, Boston, USA Disease, Hunter Medical Research Institute, University of Newcastle, NSW, 4The University of Queensland, QLD, 5Royal Adelaide Hospital, Adelaide, Introduction/Aim: Adherence to inhaled corticosteroid (ICS) treatment is SA, 6Sir Charles Gairdner Hospital, Perth, WA, 7Concord Repatriation Gen- poor, particularly in children, and can increase the risk of morbidity and mortal- eral Hospital, Concord, NSW, 8 Liverpool Hospital, Liverpool, NSW ity. However, the factors associated with adherence in this younger age group are not fully understood. This study aimed to identify factors associated with Introduction/Aim: Asthma is a heterogeneous inflammatory disease ICS adherence in school-aged children, as measured by electronic monitoring where substantial variation exists in the contribution of eosinophilic and neu- devices over 6 months. trophilic airway inflammation. However, the airway microbiota of these differ- Methods: Adherence was monitored electronically over 6 months in ent asthmatic subtypes is poorly characterized. Our aims are to determine school-aged children, who had attended a regional Emergency Department the degree of microbiota variation between individuals according to inflamma- in New Zealand for an asthma exacerbation and were prescribed twice-daily tory phenotype and to assess the extent to which subgroups differences are inhaled corticosteroids. Participants completed questionnaires assessing likely to reflect, or contribute to pathophysiology. family demographics including household size, asthma responsibility, asthma Methods: Induced sputum samples were collected from 114 stable asth- knowledge and learning styles. Multivariable analysis of factors associated matic adults during screening for the AMAZES randomized controlled trial. with adherence was conducted. – Of these participants, 55 were classified as ‘eosinophilic’,10as‘neutrophilic’, Results: One hundred and one children (mean age 8.9 years, range 6 15, 41 as ‘paucigranulocytic’ and8as‘mixed granulocytic asthma’. 16S rRNA 51% male) participated. Median adherence with inhaled corticosteroids was gene sequencing and quantitative PCR were performed. Permutational multi- 30% of prescribed (25th percentile 17%, 75th percentile 48%). Four factors variate analysis of variance and network analysis were used to identify signif- explained 30% of the variation in adherence. These were female sex (12% icant differences in taxon relative abundance between participant subgroups. greater adherence), Asian ethnicity (19% greater adherence), living with a Results: Airway microbiota was dominated by the genera Haemophilus, lower number of people in the household (adherence decreased by 0.3% Streptococcus and Prevotella, with variation in these taxa contributing most per person in the household) and younger age at diagnosis (0.3% for every < to inter-patient variance. Substantial differences in intra-subgroup similarity younger year of diagnosis) (all p 0.02). were observed, with microbiota from participants with neutrophilic asthma Conclusions: In school-aged children, attending a New Zealand ED for an showing greater dissimilarity compared with eosinophilic (p < 0.0001) or asthma exacerbation, males, and children of, non-Asian ethnicity were at paucigranulocytic (p < 0.0001) asthma. Airway bacterial load was significantly higher risk for poor ICS adherence indicating that they may benefit most from higher in neutrophilic compared with eosinophilic participants (p = 0.018). adherence intervention. We identified just four factors which explained only a Within neutrophilic asthma, two clear sub-types were identified: those with a small proportion of the variation in adherence highlighting the difficulty of iden- highly dominant bacterial taxon (typically Haemophilus) and those where the tifying universal adherence barriers. Further research is recommended to rep- predominant taxon had substantially lower relative abundance (Streptococcus licate and extend our findings in other high-risk paediatric populations. or Prevotella). Airway microbiota in participants with eosinophilic asthma was Grant Support: Health Research Council of New Zealand and Cure Kids. typified by the presence of Mycoplasma, with higher relative abundance compared with paucigranulocytic asthma (p =0.004). Conclusions: Substantial variation exists in the composition of asthma airway microbiota, with marked divergence according to inflammatory profile. Variation in composition is likely to reflect differences in airways characteristics. In addition, pro-inflammatory genera, such as Mycoplasma, and those able to cause lung infection, including Haemophilus, Staphylococcus and Moraxella, may contribute to disease directly. Grant Support: This work was supported by SAHMRI and the HMRI.

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EFFECTIVENESS AND RESPONSE PREDICTORS OF THE USE OF FRACTIONAL EXHALED NITRIC OXIDE-BASED OMALIZUMAB IN A SEVERE ALLERGIC ASTHMA MANAGEMENT FOR NON-EOSINOPHILIC ASTHMA DURING POPULATION WITH A HIGH PREVALENCE OF PREGNANCY COMORBIDITIES: THE AUSTRALIAN XOLAIR REGISTRY MURPHY V1,GIBSONP1,2 GIBSON P1,REDDELH2, JENKINS C3,MARKSG4, UPHAM J5,GILLMAN 1University of Newcastle, 2John Hunter Hospital Newcastle A6, THIEN F7, SUTHERLAND M8,RIMMERJ9, KATSOULOTOS G10,COOK 11 12 13 14 15 M ,YANGI ,KATELARISC ,BOWLERS ,LANGTOND ,ROBINSON Introduction/Aim: Fractional exhaled nitric oxide (FENO)-based manage- 16 17 18 19 1 P ,WRIGHTC , YOZGHATLIAN V , BURGESS S ,MCDONALDV,P ment for asthma during pregnancy reduces exacerbations and improves in- 20 21 22 23 1 SIVAKUMARAN , A JAFFE , J BOWDEN , M GUO , P WARK ,KY fant outcomes; however, it is not known whether this approach is effective in 2 2 3 4 6 7 YAN ,VKRITIKOS, M PETERS ,MBARAKET, M HEW ,AAZAD, women with non-eosinophilic asthma. 17 MBINT Methods: Pregnant women with asthma were recruited in the antenatal 1 Centre for Asthma and Respiratory Diseases, Department of Respiratory and clinic and randomized prior to 22 weeks gestation, to have treatment adjusted Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, by a clinical algorithm (which made step-wise adjustments to therapy based 2 University of Newcastle, New Lambton Heights, NSW 2305, Department of on symptoms) or a FENO algorithm (which adjusted inhaled corticosteroid Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW [ICS] dose according to FENO and added long-acting beta agonist [LABA] 3 2050, Department of Thoracic Medicine, Concord Hospital, Concord, NSW when symptoms remained uncontrolled). Women with blood eosinophils 4 2138, Department of Respiratory Medicine, Liverpool Hospital, Liverpool, <0.26 × 109/L and FENO ≤29 ppb at randomization were classified as non- 5 NSW 2170, Department of Respiratory Medicine, Princess Alexandra Hospi- eosinophilic. 6 tal, Woolloongabba, QLD 4102, Department of Allergy, Immunology and Results: One hundred nineteen participants were included in the analysis. 7 Respiratory Medicine, Alfred Hospital, Melbourne, VIC 3004, Department of Eighty-one women had eosinophils <0.26 × 109/L; 68 women also had low 8 Respiratory Medicine, Box Hill Hospital, Box Hill, VIC 3128, Department of FENO (57% non-eosinophilic). 9 Respiratory and Sleep Medicine, Austin Hospital, Heidelberg, VIC 3084, St At randomization, 54% of women in the FENO group used ICS (median dose 10 Vincent’s Clinic, Darlinghurst, NSW 2010, St George Specialist Centre, 400 μg/day, [400–800 μg/day]), and 6% used LABA. After applying the algo- 11 Kogarah, NSW 2217 Dept of Immunology, Canberra Hospital, WODEN rithm, this increased to 66% using ICS, at a lower dose of 200 [200–400] μg/ 12 ACT 2606, Dept of Thoracic Medicine, The Prince Charles Hospital, day (P = 0.0014) and 29% using LABA (P = 0.011). In the clinical group, 13 Chermside QLD 4032, Dept of Respiratory and Sleep Medicine, 42% used ICS at randomization (400 [400–800] μg/day) and 21% used LABA. 14 Campbelltown Hospital, Campbelltown NSW 2560, Dept of Respiratory After applying the clinical algorithm, a similar proportion were using ICS 15 and Sleep Medicine, Mater Adult Hospital, South Brisbane QLD 4101, Dept (45.5%), at a dose of 800 [400–800] μg/day (P = 0.438), and 12% used LABA 16 of Thoracic Medicine, Frankston Hospital, Frankston VIC 3199, Dept of Re- (P =0.322). spiratory Medicine, Children’s Hospital at Westmead, Westmead NSW 2145, There were significantly fewer women with exacerbations requiring medical in- 17 Dept of Respiratory Medicine, Nambour Hospital, Nambour QLD 4560, tervention in the FENO group (8/35, 22.9%, 95% CI [12.1–39.0%]) compared 18 Dept of Respiratory and Sleep Medicine, St George Hospital, Kogarah to the clinical group (16/33, 48.5%, 95% CI [32.5–64.8%], P = 0.027). All exac- 19 NSW 2217, QLD Children’s Lung and Sleep Specialists, Woolloongabba erbations were non-eosinophilic (FENO ≤29 ppb), and many involved viral in- 20 QLD 4102, Dept of Respiratory Medicine, Gold Coast District Hospital, fection (58% questionnaire reported or laboratory confirmed virus). 21 Southport QLD 4215, Dept of Respiratory Medicine, Sydney Children’sHos- Conclusion: FENO-based management was effective for women with 22 pital, Randwick NSW 2031, Dept of Respiratory, Allergy and Sleep Medi- non-eosinophilic asthma, possibly due to the early addition of LABA when 23 cine, Flinders Medical Centre, Bedford Park SA 5042, Clinical symptoms were uncontrolled. Management, Woolcock Institute of Medical Research, Glebe NSW 2037 Grant Support: National Health and Medical Research Council. Declaration of interest: None to declare. Introduction/Aim:Severe asthma is a high impact disease. Omalizumab (Xolair) targets the allergic inflammatory pathway; however, effectiveness data in populations with significant comorbidities are limited. This report describes severe allergic asthma in Australia among the Australian Xolair Regis- try participants. Methods: A web-based post marketing surveillance registry (www. australianxolairregistry.org) was established to characterize the use, effectiveness and adverse effects of omalizumab for severe allergic asthma. Results: Participants (n = 192) [mean age 51 (range 12–85) years, 118 (61%) female] with severe allergic asthma from 21 clinics in Australia were enrolled and assessed. Of these, 180 (93%) received initial omalizumab therapy. At baseline, participants had poor asthma control [mean (SD) Asthma Control Questionnaire (ACQ-5) score 3.56 (1.0)], significant quality of life impairment [Asthma-related Quality of Life Questionnaire (AQLQ) 3.57 (SD 1.22)]. Daily oral corticosteroid was used in 52% of participants. The omalizumab re- sponder rate, assessed by an improvement of 0.5 in ACQ-5, was high at 83%. Obesity (45%) and cardiovascular disease (23%) were prevalent. Re- sponse to omalizumab was similar in participants with and without comorbid obesity and cardiovascular disease. Baseline ACQ-5 score >2.0 was predictive of response to omalizumab (p = 0.002). Adverse events included allergic reactions (n = 4), headache (n = 2) and chest pains (n =1). Conclusions: Australian patients with severe allergic asthma report a high disease burden and have extensive comorbidity. Symptomatic response to omalizumab was high despite significant comorbid disease. Baseline symptoms above the PBS initiation criterion of ACQ-5 ≥ 2.0 were predictive of response to omalizumab in a real-life setting. Omalizumab is an effective targeted therapy for severe allergic asthma with comorbidity. Grant Support: The Australian Xolair Registry was supported by Novartis Pharmaceutical Australia Pty Ltd as an Investigator Initiated study.

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BREATH-TO-BREATH VARIABILITY OF RESPIRATORY SPUTUM COLOUR AS A MARKER OF NEUTROPHILIC IMPEDANCE IN ASTHMA PATIENTS BY POINCARE ANALYSIS BRONCHITIS IN ADULTS WITH ASTHMA

NGUYEN C1,2,GOBBIA3,DELLACAR3,KINGG1,THAMRINC1 SIMPSON J1,LOCHRINA1,WOODL1,GIBSONP1,2 1Woolcock Institute of Medical Research, 2Neuroscience Research Australia 1Center for Asthma and Respiratory Disease, The University of Newcastle, (NeuRA), Randwick, NSW, Australia, 3Politecnico di Milano University, Milan, 2Department of Respiratory and Sleep Medicine, Hunter New England Area Italy Health Service

Introduction/Aim: Variability of airway calibre is a characteristic feature of Introduction: Identifying inflammatory subtypes in asthma is restricted in asthma. Breath-to-breath variability of respiratory impedance, measured by clinical practice due to the lack of readily available non-invasive measures of forced oscillation technique (FOT), exhibits nonrandom fluctuations that may airway inflammation. Blood eosinophils may be a useful tool to identify those represent intrinsic, spontaneous variability in airway calibre. However, results with eosinophilic asthma where induced sputum is not available; however, showing differences in FOT variability measures between health and asthma there is no equivalent to identify patients with neutrophilic asthma. have been mixed. In this study, we examined breath-to-breath FOT variability Aim: Our aim is to examine sputum colour as a surrogate for sputum cell that occurred both between consecutive breaths and over an entire recording counts in identifying patients with asthma who have neutrophilic bronchitis. session, over 14 consecutive days. Methods: Non-smoking adults (n = 283) with asthma underwent clinical as- Methods: Ten nonsmokers (seven male) with mild asthma and 10 healthy sessment and sputum induction. Sputum colour was assigned according to controls (three male) measured FOT at home for 2 min twice a day for the Bronkotest® colour chart. Neutrophilic bronchitis was defined using the 14 days. From the morning recordings, resistance and reactance for each age-corrected 95% centile of sputum neutrophil proportion (NP), the age- breath were calculated separately for inspiration and expiration (Rinsp, Rexp corrected 95% centile for neutrophil number (NN) and using the 95% centile and Xinsp, Xexp). Poincare analysis was used to calculate variability in imped- for both total cell count and neutrophil proportion (TCN). ance parameters between consecutive breaths (SD1) and within the entire Results: The proportion of participants with neutrophilic bronchitis was sim- 2-min session (SD2). Recordings were normalized to remove within and ilar using the NP and NN method (25% compared with 23%, respectively, between subject differences in impedance and variability. The mean of the p = 0.745), while there were significantly fewer participants classified as neu- 14 daily SD1 and SD2 was then compared between groups by unpaired t-test. trophilic bronchitis using the TCN approach (10%, p < 0.001).Sputum colour Results: The asthmatic subjects’ mean ± SD age was 35 ± 15 (years) and was significantly higher in neutrophilic bronchitis irrespective of the classifica- FEV1 was 87 ± 11 (%) of predicted. The control subjects were 47 ± 11 (years) tion method (p < 0.001). Receiver operator characteristic curves showed the and 108 ± 14 (%) of predicted, respectively. Asthmatic subjects had signifi- highest area under the curve (AUC) for the TCN classification of neutrophilic cantly higher SD2 (in all FOT parameters, p < 0.04) and lower SD1 (in Rinsp, bronchitis with an AUC (95% confidence interval) of 0.815 (0.740 to 0.889), Xinsp and Xexp, p < 0.04) compared to controls (Table 1). followed by the NN method with 0.750 (0.681 to 0.812) and the NP method Table 1. Differences in variability of respiratory impedance quantified by with 0.650 (0,575 to 0.712). Poincare analysis between mild asthma patients and healthy controls A sputum colour score of 3 or more indicating mucopurulent sputum was associated with a specificity of 79.4%, 82.1% and 76.6%, respectively for SD1 SD2 NP, NN and TCN. Conclusion: A bronkotest colour of three or more may be clinically useful in Mild Mild identifying patients who have neutrophilic bronchitis and therefore may be suited to a trial of non-corticosteroidal therapies such as macrolide antibiotics. Healthy asthma P- Healthy asthma P- (N =10) (N =10) value (N =10) (N =10) value

Rinsp 0.92 0.78 0.002* 1.02 1.14 0.04* ± 0.08 ± 0.10 ± 0.12 ±0.11 Rexp 0.86 0.78 0.07 1.04 1.17 0.04* ± 0.10 ± 0.08 ± 0.16 ±0.05 Xinsp 0.98 0.85 0.001* 0.99 1.11 0.003* ± 0.07 ± 0.09 ± 0.10 ±0.06 Xexp 0.91 0.83 0.04* 1.04 1.13 0.016* ± 0.05 ± 0.11 ± 0.08 ±0.08

SD1 and SD2, breath-to-breath and within 2-min session variability of respiratory impedance; Rinsp, Rexp, Xinsp and Xexp, inspiratory and expiratory of respiratory resistance and reactance, measured by forced oscillation technique, respectively. Data are shown as mean ± SD.

Conclusion: Variability in respiratory impedance of asthmatics is lower between consecutive breaths but higher during the 2-min recording session, compared to controls. The mechanisms underlying these differences in variability between two different time scales require further study. Determining whether breath-to-breath and within session variability changes spontane- ously over time, with treatment or during exacerbations, is necessary, to evaluate its clinical utility in home FOT monitoring. Grant Support: NHMRC project grant (1065938).

TO 146 Occupational & Environmental Lung Disease/ Population Health Oral Presentations OCCUPATIONAL EXPOSURE TO VAPOUR, GASES/FUMES, DUST AND LUNG FUNCTION IN MIDDLE-AGED POPULATION

ALIF S1,DHARMAGES1, BENKE G2, DENNEKAMP M2,BURGESSJ1, TO 145 PERRET J1,3,LODGEC1,MORRISONS4,JOHNSD5, GILES G1,2,6, THOMAS P7, VERMEULEN R8,KROMHOUTH8, ABRAMSON M2, WALTERS E1,2,5,MATHESONM1 1Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, INHALATIONAL INJURY FOLLOWING THERMAL BURN—RISK School of Population and Global Health, The University of Melbourne, Victo- STRATIFICATION TOOL 2 ria, Australia, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia, 3Department of Respiratory and Sleep SENEVIRATNE I1,SIMPSONC2 4 1 2 Medicine, Austin Hospital, Victoria, Australia, University of Queensland, The Prince Charles Hospital, Brisbane, Queensland, Australia, Critical Care Queensland, Australia, 5 University of Tasmania, Tasmania, Australia, 6Can- Complex, Middlemore Hospital, Auckland, New Zealand cer Epidemiology Centre, Cancer Council Victoria, Victoria, Australia, 7Faculty of Medicine, University of New South Wales, New South Wales, Australia, Introduction/Aim: Inhalational injury has been associated with higher mor- 8Utrecht University, Utrecht, The Netherlands tality in individuals with thermal burns. The lack of clear diagnostic criteria for Introduction: identification of inhalational injury makes prognostication difficult. Our aim Occupational exposures are associated with lower lung function levels in the was to develop a risk stratification tool for prognostication that is independent general population. However, the population-based studies that have of the need for bronchoscopy and to re-evaluate previously identified prognos- assessed this association have had limitations including the use of pre-bron- tic factors and identify new unique prognostic factors for individuals with an chodilator (BD) spirometry and the use of cohort with young adults less than inhalational injury. 40 years of age. We studied the association between occupational exposure Methods: This was a single centre retrospective cohort review of all pa- and post-BD lung function using the population-based Tasmanian Longitudi- tients admitted to the Critical Care Complex (CCC) at Middlemore Hospital, nal Health Study (TAHS) where participants are all born in 1961. Auckland, New Zealand with thermal burns and associated inhalational injury Methods: between 2005 and 2010. CHAID analysis was undertaken for the Risk Strati- The present analysis included 1335 participants who had completed a work fication Tool. Correlation and logistic regression analysis were preformed to history calendar, detailed respiratory questionnaire and post-BD spirometry evaluate prognostic variables when aged 45 years. The z-scores for spirometry were calculated using the Results: One hundred eighty-four admissions to the CCC due to thermal Global Lung Initiative reference equations. Job histories were coded in to burns were identified during the study period, and 108 (59%) of these occupational exposures using the ALOHA + Job Exposure Matrix. Multivari- sustained an inhalational injury. We defined three risk groups for ICU mortality able logistic regression models adjusted for sex, smoking, pack-years, in individuals with an inhalational injury using a ‘decision tree model’—alow asthma and socioeconomic status. risk group with a predicted mortality calculated at 2–4%, a medium risk group Results: with a calculated predicted mortality of approximately 30% and a high risk The table shows the association between categories of occupational expo- group with a calculated predicted mortality nearing 100%. ICU mortality corre- sure and level of lung function. lated with female gender (Pearson correlation 0.172), increasing age (0.187), total body surface area (0.328), full thickness surface area (FTSA) (0.369) and z-score z-score z-score APACHE II score (0.272). All these values were statistically significant FEV1/FVC FEF25–75% < Occupational FEV1coeff (p-value 0.05). Inhalational injury was not significantly associated with exposures (95%CI) coeff (95%CI) coeff (95%CI) increased mortality (p-value 0.402). Logistic regression revealed that age, TBSA, FTSA, APACHEII score and highest FiO2 in the first 48 h had positive À À À OR for mortality in the ICU in individuals with an inhalational injury with Biological dust 0.06 0.11 0.14 À À À À p-values <0.05. ( 0.19, 0.08) ( 0.25, 0.03) ( 0.28, 0.01) Conclusion: The risk stratification tool for ICU mortality in individuals with an Mineral dust À0.04 À0.10 À0.13 inhalational injury is a unique prognostication tool which, unlike other prognos- (-0.17, 0.08) (À0.19, À0.02) (À0.25, À0.02) tication scores/tools is not dependant on bronchoscopy findings. Larger pro- Gases/fumes À0.09 À0.16 À0.16 spective studies are needed to validate this tool. (À0.17, À0.01) (À0.28, À0.04) (À0.28, À0.04) Grant Support: None. Vapour, gas, dust À0.10 À0.09 À0.13 and fumes (VGDF) (À0.18, À0.03) (À0.16, À0.02) (À0.25, À0.02)

*Statistically significant associations are depicted in bold.

Conclusions: We have shown using post-BD spirometry that occupational exposure to gases/fumes and any VGDF was consistently associated with lower lung function levels in this general population sample. These lower lung function levels may subsequently increase the risk of airway obstruction later in life that may contribute to the overall global burden of mortality and morbidity from COPD. Grant Support: NHMRC. Conflict of Interest: No conflict of interest.

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THE LONGITUDINAL CHANGES IN LUNG FUNCTION OF CORRELATION OF LOW DOSE CHEST CT FINDINGS WITH SOUTH AUSTRALIAN METROPOLITAN FIRE FIGHTERS PHYSIOLOGIC MEASURES OF ASBESTOSIS 2007–2015. MANNERS D1,WONGP2,MURRAYC2,KWOKY3, DE KLERK N4, CROCKETT A, MALBON W, MORGAN M, SCHERMER T ALFONSO H5,FRANKLINP4,REIDA5,MUSKA1,4, BRIMS F1,6,7 School of Health Sciences 1Department of Respiratory Medicine, Sir Charles Gairdner Hospital, WA, Introduction/Aim: Australia, 2Department of Diagnostic Imaging, Royal Perth Hospital, WA, The risks for fire fighters in developing lung diseases due to their exposures to Australia, 3Department of Diagnostic Imaging, Sir Charles Gairdner Hospital, toxic fumes and pollutants were highlighted in the years subsequent to the WA, Australia, 4School of Population Health, University of Western Australia, World Trade Centre disaster in 2001. Associations between exposures and WA, Australia, 5Centre for Population Health Research, Curtin University, WA, lung function decline have been demonstrated by several longitudinal epide- Australia, 6School of Medicine and Pharmacology, University of Western miological studies of New-York Fire Fighters. The purpose of this longitudinal Australia, WA, Australia, 7Institute for Respiratory Health, WA, Australia study has been to obtain objective data of the SA Metropolitan Fire Fighters Introduction/Aim: respiratory function and to monitor the rate of decline of their lung function over Low dose computed tomography (LDCT) technology enables image acquisi- time. tion at very low radiation doses. LDCT is increasingly being used in asbes- Methods: Baseline spirometry was performed according to ATS/ERS criteria tos-exposed populations, but the correlation between LDCT-detected using Viasys MasterScreen® spirometry system. Questionnaire data relating parenchymal lung changes and pulmonary function abnormalities is not to respiratory symptoms and quality of life were collected at the time of testing. known. The aim of this study was to determine the relationship between Both spirometry and questionnaire data were analysed using SPSS V15®. The LDCT-detected interstitial lung disease (ILD) and measures of pulmonary study received ethics approval from The University of South Australia Human function. Research Ethics Committee. Methods: Results: LDCT readings and pulmonary function tests of former miners and township The South Australian Metropolitan Fire Service Study (SAMFSS) recruitment residents exposed to blue asbestos at Wittenoom were analysed. Two tho- phase for baseline questionnaire and lung function testing commenced on racic radiologists independently categorized LDCT ILD appearances as ab- 14-08-2007 and the fourth round of data collection was completed on sent (score 0), probable (1) or definite (2) without knowledge of asbestos 30-5-215.A total of 775 fire fighters participated in the study to date; 525 com- exposure or level of lung function. Inter-observer agreement was evaluated pleted their baseline lung function test and at least two other tests. with Cohen’s kappa test. Pulmonary function measures included spirometry Twenty-one percent (163) of the male fire fighters had a FEV1/FVC ratio less and diffusing capacity to carbon monoxide (DLCO). The correlation between than the lower limit of normal which suggests airflow obstruction. However, the variables was determined by Spearman’s correlation coefficient. FEV1, the main measure of airflow obstruction, was only less than 80% of the Results: Australian predicted normal value in 1.9% of the men. Fifteen point three per- One hundred forty-three participants (130 (93%) males) of median (IQR) age cent of the male fighters had a rate of decline of FEV1 greater than 90 mL/ 73.0 (69.8–76.9) years were included. Mean cumulative asbestos exposure year. Eighty percent had no change with 4.7% demonstrating an increase in was 11.5 ± 29.9 (SD) fibres/mL/year, and mean DLCO was 21.6 ± 6.5 (SD) lung function of great than 90 mL/year independent of age. mL/min/mmHg. Mean effective radiation dose estimate was 0.8 (range Conclusion: 0.3–1.8) mSv. 63/143 (44.1%) of participants had probable or definite ILD This survey has provided baseline data on the respiratory symptoms and lung scores. Inter-observer agreement was high (k = 0.613, p < 0.001). There function on 76% of the current fire fighters. The majority of fire fighters demon- was a statistically significant correlation between ILD score and both cumula- strated no change or an increase in FEV1 over time which was unrelated to tive asbestos exposure (r = 0.194, p =0.01) and DLCO (r = À0.335, age. p < 0.0001) but no correlation between ILD score and FEV1/FVC ratio (r = 0.048, p = 0.571). Conclusions: Changes consistent with interstitial fibrosis on LDCT correlate well with cumulative asbestos exposure and corresponding reductions in gas transfer, similar to HRCT. In asbestos-exposed populations, LDCT may be used in lieu of HRCT to reliably detect asbestosis. Grant funding: WA Department of Health.

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MALIGNANT MESOTHELIOMA IN ABORIGINAL PEOPLE IN MESOTHELIOMA IN AUSTRALIA—RESULTS FROM THE WESTERN AUSTRALIA AUSTRALIAN MESOTHELIOMA REGISTRY

FRANKLIN P1,REIDA2, PETER S1,BRIMSF1,DEKLERKN3,MUSKB1 SIM M1,LAWSP2,BENKEG1,MACFARLANEE1,BRIMSF3, DRISCOLL T4, 1The University of Western Australia, 2Curtin University, Western Australia, VAN ZANDWIJK N5 3Telethon Kids Institute, Western Australia 1Monash University, 2Cancer Institute NSW, 3University of Western Australia, Introduction/Aim: The mining and milling of blue asbestos (crocidolite) at 4University of Sydney, 5Asbestos Diseases Research Institute Wittenoom caused extensive contamination of the area and has been respon- Introduction/Aim: sible for many cases of malignant mesothelioma (MM) in those who either Australia has one of the highest incidence rates of malignant mesothelioma in worked or lived there. The local Aboriginal people were exposed to crocidolite the world. The exact mechanism of mesothelioma development is only partly both as workers for the mining operation and as long-term residents of the understood; however, it has been linked to occupational, and increasingly, lands in and around Wittenoom. The aims of this study were to describe the non-occupational exposures to asbestos. The Australian Mesothelioma Reg- incidence of MM in Western Australian (WA) Aboriginals and determine the istry (AMR) collects incidence and mortality data on all cases of mesothelioma contribution of the Wittenoom mining operations to the disease in Australia, including detailed information on asbestos exposure. The AMR Methods: All MM cases in Western Australia, as well as the primary route of includes data on diagnoses from 1 July 2010 onwards. asbestos exposure, are recorded in the WA Mesothelioma Register. Aborigi- Methods: nal cases up to the end of 2013 were extracted from the register and com- The AMR compiles fast-tracked notifications from state/territory cancer regis- pared with non-Aboriginal cases with regard the primary route of exposure. tries, but patients and clinicians can report directly. Clinicians may be Age standardized incidence rates for each decade from 1980 were calculated requested to advise if their patients are suitable for recruitment to the asbestos and compared with non-Aboriginal rates. Age standardized mortality rates exposure component. Consenting participants complete a job and residential were calculated for the period 1994–2008 and compared with international history questionnaire, followed by a tailored telephone interview using rates. OccIDEAS, an online exposure assessment tool which collects information Results: There were 39 cases (77% male) of MM among WA Aboriginals. on occupational asbestos exposure using job specific modules and environ- Twenty-six (67%) were a direct result of the mining of crocidolite (via occupa- mental asbestos exposure using an environmental module. tional (n = 17) and non-occupational (n = 9) routes). Of the non-Aboriginal MM Results: cases (n = 2070, 86.3% male) less than 25% can be attributed to Wittenoom. More than 600 cases of mesothelioma per year have been notified to the Aboriginals had consistently higher 10-year incidence rates than non-Aborig- Registry for diagnoses in 2011, 2012 and 2013. At 31 May 2015, the AMR inals and, when compared to world populations, the highest mortality rate has received 641 notifications of people newly diagnosed with mesothelioma internationally. in 2014. The age-standardized incidence rate in 2014 was 2.5 cases per Conclusion: Compared with non-Aboriginals the Wittenoom mining opera- 100 000. Exposure assessments conducted within the AMR framework dem- tion has had a disproportionate effect on MM incidence in the local Aboriginal onstrated that of 449 participants, 268 (59.7%) had ‘possible’ or ‘probable’ population. occupational asbestos exposure, while 181 (40.3%) had ‘unlikely’ occupa- Grant Support: Nil. tional exposure. Three hundred seventy-seven cases (84% of all cases) had ‘possible’ or ‘probable’ asbestos exposure in non-occupational contexts, while 24 cases (5.3%) had no identifiable exposure from occupational or environmental sources. Conclusion: AMR information provides an assessment of sources of asbestos exposure currently contributing to causing newly diagnosed mesothelioma cases in Australia. The AMR is a national resource which can assist in identifying important sources of asbestos exposure to help guide prevention programs. Grant Support: Safe Work Australia and Comcare.

TO 152 Lung Cancer 2 Oral Presentations

LUNGSCREEN WA PROJECT—12 MONTHS OF LOW DOSE CT LUNG CANCER SCREENING TO 151 MANNERS D1,BRIMSF1,2,3, MCWILLIAMS A2,4 1Department of Respiratory Medicine, Sir Charles Gairdner Hospital, 2School of Medicine and Pharmacology, University of Western Australia, 3Institute for LUNG CANCER RESEARCH OUTPUT IN AUSTRALIA IS Respiratory Health, 4Department of Respiratory Medicine, Fiona Stanley POORER THAN THE GENERALLY POOR INTERNATIONAL Hospital LEVEL Introduction/Aim: Screening high risk current and former smokers with low dose computed PETERS M1,AGGARWALA2,FOXJ3,SULLIVANR tomography (LDCT) can reduce lung cancer deaths, but lung cancer screen- 1Faculty of Medicine and Health Sciences, Macquarie University, 2Institute of ing is not currently recommended in Australia. Incorporation of risk prediction Cancer Policy, Kings College, London, UK, 3Roy Castle Lung Cancer Centre, models to assess eligibility and guide nodule management can improve Liverpool, UK screening efficiency. The LungScreen WA Project aims to assess the effec- Introduction/Aim: tiveness and feasibility of community based lung cancer screening in Austra- Lung cancer (LC) is the leading cause of cancer mortality in Australia. Only lia. It is the only on-going lung cancer screening study for smokers in Australia. research will reduce the burden of disease and improve outcomes. There is Methods: This is a prospective cohort study. Current or former smokers aged – a common belief that it is hard to attract LC research funding and that research 55 74 years are self-referred via advertising. The 6-year lung cancer risk is ≥ activity and output are inadequate. To quantify this, we present the results of a determined by the PLCOM2012 risk calculator. Only participants with 1.5% comprehensive analysis of global LC research from 2004 to 2013 PLCOM2012 risk are screened with LDCT. Nodule follow-up is determined Methods: We used a validated bibliometric analysis of research outputs from by Brock malignancy risk score. All participants undergo repeated quality of 24 leading cancer research countries based on articles and reviews in the life assessment and health resource utilization. Web of Science (WoS) database identified using a specifically developed Results: algorithm. Areas of interest for each publication and actual citation impact Seventy-six participants have been recruited, and 51 (67%) were ≥ (ACI) were determined. Sources of research support were identified for each PLCOM2012 risk 1.5% and offered LDCT. Of these 51 participants, the publication. mean age was 65.7 ± 5.3 (SD) years; 26 (51%) were female, and 23 (45%) – Results: Globally, 5.1% of all cancer publications were in LC. Predominant were current smokers. The median PLCOM2012 risk was 3.6% (IQR 2.65 areas of interest are genetics, chemotherapy and prognostic factors. Palliative 6.05). Currently, 45 (88%) have undergone LDCT screening, 3 (6%) have care and quality of life research was only 0.5% of global output. Australia LDCT pending and 3 (6%) declined further participation. Pulmonary nodules ranked 12th for all cancer but 14th for LC. Only India, Brazil and Sweden of any size were detected in 26/45 (58%). Indeterminate nodules with a malig- ≥ had a lower LC fraction. Australian publications doubled between 2005 and nancyriskscore 6% were detected in 9 (20%). One participant was diag- 2012. We have now passed Belgium and Greece. Australian ACI was 13.9 nosed with Stage IB lung adenocarcinoma and treated with resection. Of the —lower than world average of 16.1. Compared to similar countries, a small current smokers who have completed 2-month follow-up, 2/9 (22%) have quit fraction of Australian research is supported by the government and major smoking. charity research funding. Conclusions: Conclusions: Relative to burden of disease, LC research output is low glob- Community based LDCT lung cancer screening of high-risk individuals utiliz- ally reflecting resourcing and particularly low in Australia. Skills in Australia for ing risk prediction models is feasible. This early data are encouraging and fur- cancer research are not devoted to LC in proportion to clinical needs of current ther recruitment with long-term follow-up and healthcare economic data are patients and those at risk. Areas of high need such as palliative care are poorly required. researched. A higher proportion of research in Australia appears to be based Grant Support: WA Cancer and Palliative Care Network, WA Department of on soft funding. Substantial, targeted research funding for lung cancer that will Health, Envision Medical Imaging. lift research productivity is needed. Conflict of Interest: None declared. Grant Support: Global Lung Cancer Coalition.

TO 153 TO 154

PRELIMINARY RESULTS USING MULTILEAF COLLIMATOR PRESENCE OF PLEURAL PLAQUES AND/OR ASBESTOSIS TRACKING (CALYPSO BEACONS) FOR DIRECTED AND THE RISK OF LUNG CANCER IN A CROCIDOLITE RADIOTHERAPY FOR LUNG CANCER—AN AUSTRALIAN ASBESTOS EXPOSED POPULATION FROM WESTERN FIRST AUSTRALIA

HERSCH N1,HADDADC2,BOOTHJ2,3, CAILLET V2,3, HARDCASTLE N2,, BRIMS F1,2,3,MUSKB1,2,4,REIDA5,PANGS1,FRANKLINP4, PETERS S4, HIBBERT M1,DONG1,EADET2,3, STEVENS M2,KEALLP2,3,HARRISB1 DE KLERK N4 1Respiratory Department, Royal North Shore Hospital, NSW, Australia, 2Radi- 1Sir Charles Gairdner Hospital, 2School of Medicine and Pharmacology, Uni- ation Oncology Department, Royal North Shore Hospital, NSW, Australia, versity of Western Australia, 3Institute for Respiratory Health, Perth, WA, 3The University of Sydney, School of Physics, NSW, Australia 4School of Population Health, University of Western Australia, WA, 5Centre Introduction/Aim: Patients receiving radiotherapy for lung cancer frequently for Population health Research, Curtin University, Perth, WA have co-existent lung disease. Strategies to minimize collateral damage to Introduction/Aim: Asbestos exposure is associated with dose-dependent non-cancerous lung are key. However, due to respiration, tumour movement risk of benign pleural disease, lung cancer and mesothelioma. While an asso- during radiotherapy delivery requires expansion of the treatment field. LIGHT ciation between asbestosis and lung cancer (even after adjustment for asbes- SABR tracks tumour movement using multileaf collimator (MLC) technology tos exposure) is well established, the link between lung cancer and the from bronchoscopically implanted Calypso beacons. By guiding radiotherapy presence of pleural plaque remains controversial with a recent report recent beams with beacon tracking, it is proposed that planned target volumes report containing small numbers of lung cancers (from death certificates) (PTVs) can be reduced. We report the preliminary findings of this world first reporting an association. clinical trial using beacon-guided radiotherapy for real-time tracking and sub- Methods: We followed 2218 subjects exposed to crocidolite asbestos as sequent radiotherapy for lung malignancy. miners (n = 1286) or mine township residents, monitored with annual review, Methods: LIGHT SABR aims to recruit 20 patients with early stage lung can- chest radiography (CXR) and outcome linkage to national cancer and mortal- cer or oligometastases. Patients undergo beacon implantation using standard ity registry data over a 25-year period. Subjects were followed up from the date fibreoptic bronchoscopy under conscious sedation. Three beacons are of their latest X-ray taken a year or more before the date of death, cancer inci- deployed under image intensification aiming to surround the tumour. After suc- dence or end of follow-up. Hazard ratios for lung cancer were estimated by cessful implantation, patients undergo a 4D-CT scan to quantify tumour move- Cox regression, with age as the underlying matching time variable, for sex, to- ment during tidal breathing. Treatment target volumes are then calculated bacco smoking, asbestos exposure estimates (time since first exposure and using standard stereotactic planning protocols and compared to those calcu- fibre/mL years), International Labour Organisation CXR readings for asbesto- lated using the MLC tracking technique. sis (defined as profusion score > 1/0) and presence (and extent) of pleural Results: To date, two patients have been implanted and planned. Both pa- plaques. tients have successful implantation with no adverse events. Neither have Results: Mean age at follow-up was 60.6 years; 1575 (71%) were male; 328 been classified as ineligible due to unacceptable positioning of the beacons. (14.8%) had any pleural plaque, and 359 (16.2%) had asbestosis. One hun- Early data show good correlation between the centre of tumour volume and dred three (4.64%) lung cancers were recorded. One thousand five hundred the beacons’ centroid (patient 1: r =0.73, p = 0.2; patient 2: r =0.97, sixty-eight (70.7%) were ever-smokers with a mean tobacco exposure of p < 0.0001) indicating beacon movement is a good surrogate for tumour 39.3 pack years. Hazard ratios are presented in Table 1.Conclusions: In movement. Planned target volumes show a reduction between standard ste- our population, the presence of pleural plaque is not associated with an in- reotactic and MLC tracking techniques of 13% and 53% for patients 1 and 2, creased risk of subsequent lung cancer. As we have demonstrated previously, respectively. the presence of asbestosis and cumulative asbestos exposure both contribute Conclusion: The preliminary data in LIGHT SABR suggest that (a) to increased subsequent lung cancer risk, although previous tobacco smoke endobronchial placement of beacons is safe and effective; (b) beacons are exposure remains the strongest risk factor. an accurate surrogate for tumour movement; and (c) tumour target volumes will be reduced using the MLC tracking technique thereby minimizing the dam- HR Lower 95% CI Upper 95% CI p-value age to surrounding lung. Grant Support: Collaborative Research Partnership with Varian Medical Sys- Log (years) TSFE 1.77 0.60 5.22 0.298 tems and the Department of Radiation Oncology, Clinical Trials Trust Fund. Ever smoker 18.1 2.5 132 0.004 Pack years 1.009 1.005 1.01 <0.0005 Profusion: 0/1 1.88 1.14 3.10 0.013 1/0 1.64 0.87 3.07 0.124 1/1 3.64 1.83 7.24 <0.0005 1/2 6.10 2.03 18.3 0.001 > 2/1 2.18 0.64 7.49 0.215 Log f/mL years 1.223 1.076 1.390 0.002 Any PP 1.048 0.601 1.826 0.869

TSFE, time since first exposure; f/mL, fibres / mL; PP, pleural plaque; HR, hazard ratio; CI, confidence interval.

Grant Support: Nil. Conflicts of interest: None.

TO 155 TO 156

MDT DATA CONSENSUS IN LUNG CANCER: A NEW THE AUSTRALASIAN MALIGNANT PLEURAL EFFUSION-2 STRATEGY (AMPLE-2) TRIAL

STONE E1, RANKIN N2,PHILLIPSJ3,FONGK4,SHAWT5 THOMAS R1,2,3,AZZOPARDIM1,3,READC2,MURRAYK4,LEEY1,2,3 1St Vincent’s Hospital, Sydney, Sydney Catalyst, 2Sydney Catalyst, 3Sydney 1Respiratory Dept, Sir Charles Gairdner Hospital, Perth, WA, 2Institute for Catalyst, 4University of Queensland, 5Sydney Catalyst Respiratory Health, Perth WA, 3School of Medicine and Pharmacology, Introduction/Aim: University of Western Australia, 4Centre for Applied Statistics, University of Data collection in lung cancer has become highly topical and the focus of Western Australia much effort in development at both local and national levels. Important registry Aim: AMPLE-2 is a multi-centre, open-labelled, RCT that aims to define the level strategies have developed datasets for improved population-based data best drainage regime to improve breathlessness in patients with a malignant capture. However, in administrative and epidemiological datasets, much infor- pleural effusion (MPE) treated with indwelling pleural catheter (IPC). mation is collected ‘behind time’, is retrospective in nature and difficult to IPC is an established management option for MPE that provides good symp- access. There is no unifying data strategy for multidisciplinary (MDT) lung tom control and reduces invasive procedures and hospitalization (vs talc cancer care in Australia, even though the model of MDT care has increasing pleurodesis). No consensus exists on the best IPC drainage practice. Some support at policy level and in published outcome data. This project aims to centres advocate aggressive (daily) drainages, while others favour drainage develop a consensus dataset that is collected prospectively at MDT meetings, only when breathless (often weekly/fortnightly). Daily drainage demands con- is available in real time, is highly relevant for clinicians at point of care and that siderably more resources and costs but may theoretically provide better symp- ultimately provides information for rapid data feedback in the clinic. tom control and pleurodesis. Methods: Study design: Eighty-six patients with a symptomatic MPE will be random- A panel of expert clinicians engaged in MDT lung cancer care around Austra- ized 1:1 to aggressive (daily) or symptom-guided drainage after IPC insertion. lia will be invited to participate in an online survey and modified Delphi pro- Minimization criteria include cancer type (mesothelioma), ECOG, trapped cess. Potential panellists will be identified and contacted through a number lung and prior pleurodesis. Patients with expected survival of <3 months, sig- of sources including professional bodies such as Thoracic Society of Australia nificant fluid loculations or inability to comply with the protocol are excluded. and New Zealand, the Australasian Lung Trials Group and the Clinical Oncol- Primary outcome: Mean daily breathlessness score measured over the first ogy Society of Australia. The online survey and subsequent rounds will seek 60 days using a 100-mm visual analogue scale (VAS). consensus on an initial broad dataset developed by the investigator team. Secondary outcomes: Activity levels (tri-axial accelerometer), QoL (VAS Data items will be evaluated according to a 5-point Likert scale and a final and EQ5D), complications, hospital days and healthcare costs. dataset will be ascertained and emailed to the expert panel after the final Study sites: Sir Charles Gairdner Hospital (lead site) and 12 centres in Aus- round of consultation. Completion of the survey will act as a proxy for written tralasia, Singapore and Hong Kong. consent. Statistical analysis: Powered (5% significance and 90% power) to detect a Discussion: mean difference in VAS of 14 mm between groups and a 10% dropout rate. This project seeks to address a gap in lung cancer data collection, to identify Data will be analysed on an intention-to-treat basis. Difference between the and obtain consensus on a dataset relevant to practising MDT clinicians, that two groups will be estimated using a linear mixed-effects model. will be collected prospectively at MDT and that will support future work on real- Timeline: Study opened at Sir Charles Gairdner Hospital in September 2015; time data feedback. other sites will open pending local ethics approval. Grant Support: Sydney Catalyst Pilot and Seed Funding. Significance of study: AMPLE-2 addresses a practical question pertinent to the care of MPE with direct impact on patient management and healthcare resources. Grant Support: Sir Charles Gairdner Research Advisory Committee project grant. Declaration of Interest Statement: Nil.