7^th International Chronic Obstructive Pulmonary Disease Conference October 22-23, 2018 Rome, Italy

Marousa Kouvela is a private practice Pulmonologist. She completed her Residency at “Evangelismos” Hospital which is one of the largest general hospitals in Greece and achieved her speciality Board Degree in 2013. She has completed her Master of Science Degree in Thoracic Oncology. She has participated in many national and international scientific and educational seminars and published in national and international journals. Her special scientific interests are COPD, lung cancer and interventional pulmonology. She has worked as a Medical Manager Respiratory in Boehringer Ingelheim Ellas, Greece. She currently works as a Clinical Fellow at the Oncology Department of the General Hospital of Chest Diseases “Sotiria”, University of Athens, Greece.

Inhalation is the preferred method for medication delivery in COPD and asthma. The choice of the respiratory tract as the drug delivery route over other routes (e.g. per OS or IV) offers not only better lung deposition of the medication but also less side effects. So, by using an inhaler device we can achieve optimal drug efficacy with lower medication doses and a more rapid onset of action. As COPD progresses, breathing becomes difficult as inspiratory capacity is reduced. This is even more perceptible during COPD

exacerbations, when patients need even more efficient and fast acting medications. Aiming at the COPD symptoms’ relief, all the available inhaler devices can achieve an optimal lung deposition, if they are used appropriately. The several inhaler devices that are available nowadays are divided in three main groups (metered dose inhalers, dry powder inhalers and soft mist inhalers), but even within groups there are many differences between the devices. These differences make each device unique for its use and properties.

The optimal use of the inhalers is based on the understanding and the correct demonstration of their use, but also on the fitting to the patient’s needs and preferences. The purpose of this presentation is the understanding of the mode of action of the available inhaler devices and the differences between them, the importance of the demonstration of their use to the patients and the matching of each inhaler to the specific needs of every patient.

Camilo Corbellini is a skilled Respiratory Physiotherapist at Casa di Cura Villa Serena Piossasco, Italy, with experience in the treatment and research of respiratory diseases in adult and elderly patients. He graduated in Brazil in 2002. Since 2010, he is studying and working in Italy. He has an MSc in Medical Sciences (Brazil) and in Respiratory Physiotherapy (Italy) and a PhD in Physiology from Milan University.

COPD causes airway obstruction that is not fully reversible and causes changes in the rib cage structure. These modifications lead to respiratory muscles functional inefficiency that is strongly correlated to lung function loss. Specifically, the diaphragm undergoes a progressive process of muscle fibers shortening, consequence of lung hyperinflation and dead space increase. This results in a chronic mechanical disadvantage that impairs the diaphragm’s mobility. This impairment may worsen in COPD exacerbations, improving after pulmonary rehabilitation. The diaphragmatic mobility (DM) is mostly assessed with techniques that expose the patient to risks. The ultrasonography in M-mode is easy to use, is safe and measures directly the diaphragmatic dome displacement. The study aimed to determine whether the COPD, according to the subjects’ COPD severity, impairs the DM and to verify DM improvements after an inpatient pulmonary rehabilitation. We performed lung function tests and diaphragmatic M-mode ultrasonography in COPD individuals and healthy subjects. Ultrasonography was performed during rest breathing and deep inspirations. The COPD subjects underwent six-minute walk test and arterial blood gas analysis. After initial screening, 46 COPD patients ended the rehabilitation. The mean characteristics in healthy individuals and COPD subjects: The DM during rest breathing and deep inspirations were correlated to FEV1 decrease (r=0.74; p<0.01 and r=-0.8; p<0.01, respectively). The correlation was also positive between the deep inspiration and the inspiratory capacity (r= 0.64 with p<0.001). After the rehabilitation, the DM increases during deep inspiration from 4.58cm ± 1.83cm to 5.45cm ± 1.56cm (p<0.01). It could be concluded that M-mode ultrasonography showed DM impairment is correlated to lung function loss in COPD subjects. The patients who completed the rehabilitation improved the diaphragmatic mobility verified during deep inspirations.

Lyubima Despotova-Toleva MD, PhD is a Medical Doctor with acknowledged specialties in Paedicatics, Family Medicine, Health Care Management and specialization in Paediatric Cardiology. She is a University Professor of Plovdiv Practice/Family Medicine, Scientific Advisor of PhD students, Chairperson of the Bulgarian Long-term and Palliative Care Society. Also, she is the Editor-in-Chief of Folia Palliatrica journal, Board Member of EMA, EGPRN and Lifetime Member of WONCA, IAHPC and WHPCA. She is the Author of more then 150 scientific publications, over 30 monographs, textbooks and manuals. She is the Leader, Coordinator and Senior Researcher in more than 20 international and national research and educational projects and programs (Fulbright, JSPS, mEducator, SmokeFreeBrain etc).

Helena Binetskaya is CEO and co-founder of a medical device startup Healthy Networks. LSE alumni and Quality assurance engineer in the past, she ventured into respiratory world after her baby daughter started coughing badly. Worried about pneumonia, she took her to a hospital - only to find out it was a nasal drip. Upon returning home, she discovered dozens of PubMed articles on Computer Lung Sound Analysis outperforming humans. Together with PhDs in Respiratory from Belarus LungPass, a very affordable device for early detection and monitoring of lung conditions was created.

Statement of the Problem: COPD exacerbations contribute significantly to the total COPD burden on the healthcare systems due to considerable morbidity and mortality associated with COPD. At the same time, it is now recognized that many exacerbations are delayed to be reported or are not reported at all to healthcare professionals. This results in significant impact on exacerbation outcomes, hospitalization, and health status. Early detection and prompt treatment of COPD exacerbation can reduce their impact on health status and health care utilization.

Methodology & Theoretical Orientation: LungPass—an innovative device that can be used for early detection and monitoring of lung conditions, including COPD exacerbations. It works on the basis of lung sound detection using a digital stethoscope with a subsequent evaluation of auscultation data and questionnaires (including symptoms, peak expiratory flow rate (PEFR), adherence to therapy, etc.) through a developed mobile application. The first step of our study after the algorithm development was evaluation of its accuracy in lung sounds detection compared with “gold standard” and individual practitioners. The second step will be assessment of the possibility of using the device for early detection COPD exacerbations and managing them in cooperation with healthcare providers.

Findings: 300 audio records from patients with bronchitis, pneumonia, asthma and COPD were classified by the developed diagnostic algorithm and the overall classification accuracy was 90.8% (for normal breathing sensitivity (Sn): 82%, specificity (Sp): 99%, for wheezes+rhonchi Sn: 93%, Sp: 99%, for coarse crackles+fine crackles Sn: 98%, Sp: 90%). To date, a study protocol for second step of our research has been developed.

Conclusion & Significance: The developed device and app demonstrated high lung sound classification accuracy and together with analyzing change of symptoms, daily activity, using of short-acting bronchodilators, PEFR, etc. may be used for monitoring and early detection of COPD exacerbations.

Liam Knox is a Research Officer in Hywel Dda University Health Board and currently a Health Psychology PhD candidate at Aberystwyth University, Wales. His research focuses on the use of technology enabled care services to promote health and self-management abilities in patients with chronic conditions. He supports multiple NHS research projects across a diverse range of conditions, being primarily responsible for study oversight, recruitment, and data collection. Recently, he has joined the team investigating the effectiveness of virtual pulmonary rehabilitation (VIPAR), providing both quantitative and qualitative research methods and data analysis support.

Statement of the Problem: For individuals with a chronic respiratory condition, pulmonary rehabilitation (PR) is very costeffective and hence should be an integral part of their care. National standards state that all eligible patients are offered PR but the UK COPD Audit Programme (2016) highlighted the wide variation in PR provision across Wales and only 31% of eligible patients in our region of 400,000 people received it. This was partly due to funding, recruitment of staff and also the rural environment where disabled people are expected to travel 30–100 miles, twice a week for seven weeks to attend a program.

Methodology & Theoretical Orientation: Investing into telemedicine and video conferencing helped us develop a hub and spoke model where a standard PR course of 10 patients (hub) was transmitted in real-time to a class of eight patients in a rural community hall (hub) using only two extra staff. Standard data was collected pre and post PR programmes. Patient focus groups were held to learn about patient experiences of pulmonary rehabilitation (PR), the video-conferencing (VC) and aspects they would like to see changed/improved.

Findings: Both groups were found to be similar at baseline at typical PR cohorts. Early evaluation (two courses–36 patients) suggests that this is safe, popular and of similar efficacy. Similar improvements were seen in the hub and spoke groups for incremental shuttle walk test, hospital anxiety and depression score and COPD assessment test. Focus groups highlighted that patients were extremely satisfied with the PR programme and the confidence and the abilities they have regained.

Conclusion & Significance: Pilot data show virtual PR is safe and feasible, allows care closer to home and is likely to be costeffective. Our experience so far in delivering PR via video-conferencing between one hub and one spoke site shows virtual PR delivery seems a viable option to improve local delivery of care and reduce waiting times at less cost than a second fully-staffed program.

Zhanna Laushkina works as a leading Senior Researcher and a Physician at the Novosibirsk Tuberculosis Research Institute. At the age of 28 she successfully presented results of her PhD research work. In 2016 she defended her doctoral dissertation. The areas of her research work are the problems of differential diagnosis of pulmonary tuberculosis and other lung diseases and treatment of pulmonary tuberculosis. She is has published 35 papers in reputed journals.

Background: Lung cancer is one of the leading causes of death worldwide. The delay in diagnosis of lung cancer worsens prognosis of the disease. Reducing diagnostic delay could reduce mortality.

Aim: The purpose of the study was to define factors associated with a delay of lung cancer diagnostics.

Methods: Medical reports of 55 patients with lung cancer were analyzed. Clinical presentation, radiological, laboratory data of all patients was collected. Odds ratios (OR) and nominal 95% confidence intervals (CI) were presented.

Results: Mean age of patients 58.4±13.8 yrs. Men in the study were 37 (67%). The period from the disease manifestation up to making a true diagnosis was 90.4±77.3 days, patients delay was 32±38 days. 44% of the patients were previously treated of an assumed pneumonia before hospitalization in TB hospital. All patients have been hospitalized with wrong diagnosis of pulmonary TB, a principal cause-misinterpretation of chest radiogram. 48% of lung cancer patients mistakenly treated for TB for a long time. Factors associated with increase of diagnostic delay were: acute onset of the disease (OR: 0.4, 95% CI: 0.2–0.8), fever (OR: 0.4, 95% CI: 0.2–0.8), absence of symptoms (OR: 0.4, 95% CI: 0.1–0.9), absence of hematological changes (OR: 0.3, 95% CI: 0.1–0.7), nonspecific microbial growth in sputum (OR: 0.1, 95% CI: 0.01–0.7) and detection of acid-fast bacillus (AFB) in sputum (OR: 0.2, 95% CI: 0.06–0.7). Factors associated with decrease of diagnostic delay were also found.

Conclusions: Before the establishment of a true diagnosis, patients with lung cancer had over diagnosis of tuberculosis and community-acquired pneumonia. It can be said that diagnosis requires histological confirmation.

Junling Huang has her frontline experience in pharmaceutical and medical device industry. Mercury previously worked in hospital and the pharmacy as a licensed pharmacist in China. She also had led Global Brand strategy Director role and served in several pipeline and marketing roles at large pharmaceutical enterprise in China. Strength areas cover: research, program set up & strategy implement, key account build up & maintenance, business development, marketing and customer service.

Nebulizer therapy is an effective and efficient way to deliver medications directly into the lungs by inhalation. Since the medication goes straight to the lungs, onset of the medication’s action often takes place rapidly. Nebulizers are used to treat the symptoms of conditions like Chronic Obstructive Pulmonary Disease (COPD), asthma, emphysema and chronic bronchitis. Also, it minimizes the risk of side effects of the medication, preventing the medication from being metabolized into a less effective form by the body. Several classes of drugs can be used in a nebulizer, depending on the condition for which the nebulizer is being used. Particle size for inhaled medications must be smaller than 5 microns for the medication to reach the smaller tubes in the lungs. Using a nebulizer can be a simple, beneficial and safe way to deliver inhaled medications directly into the lungs. Nebulizers can be used at home, or in a hospital or another medical setting. For those with lung conditions, treatments may be used several times a day or only when the condition is acute. There are several types of nebulizers, and some may be incompatible with certain medications. Smart and portable Mush nebulizer are produced for home use and are the least expensive and most popular.

Randall Debattista is a Junior Physiotherapist in University of Malta with special interest in Respiratory Physiotherapy. He is currently working at the main Rehabilitation Hospital on the Maltese Islands. His interest in Pulmonary Rehabilitation inspired him to look into further details with regards to new modalities which are being investigated in order to help patients with respiratory complications, mainly COPD. He is aiming to further his studies in this field especially looking more in depth with regards to the use of NMES in COPD patients.

Neuromuscular electrical nerve stimulation (NMES) is a new modality being investigated for its effect related to quadriceps strength and walking distance in chronic obstructive pulmonary disease (COPD) patients. The purpose of this small pilot study was to observe and absorb as much information possible on the methodology and learning outcomes. Information from this small pilot study would present recommendations for the possibility of a larger national study regarding this new modality. For this aim, a mixed method approach was deemed appropriate. A total of seven moderate to severe COPD patients were included in this feasibility study, four in the experimental group and three in the control group. Following patient consent, the quadriceps strength as well as a 6-minute walk test (6MWT) was completed. The objective measures were taken at the baseline of this study, i.e. week four and week eight. Positive outcomes were reported in all subjects with the experimental group benefitting the most. However, the results are insignificant in view of the small population sampling. A self-designed questionnaire was distributed to the experimental group at the end of the study, with the aim to get a better view on how patients felt during the duration of NMES. Constant feedback was kept during the study duration between the researcher, intermediary physiotherapist and the subjects. Constant feedback and the results from the questionnaire were important for the researcher to present recommendations based on the strength, limitations and learning outcomes. This feasibility study provided guidance for larger more randomized national studies to maximize the benefits of NMES in COPD patients.

Maritess Jewson is a certified Music Therapist in the UK and was diagnosed with Pulmonary Hypertension in 2008 by the specialists at the Royal Brompton Hospital in London. Since Maritess’ diagnosis she is passionate about raising as much awareness as possible for this condition. Maritess leads awareness campaigns online to reach people in the social media network to help those with PH to understand their condition and to make people who have not heard of Pulmonary Hypertension aware of the seriousness of this condition and how it affects people’s lives. Maritess’ awareness campaigns reach thousands of people everyday and she works endlessly to make these campaigns heard across the world. Maritess is an Ambassador for the Pulmonary Hypertension Association UK (PHA UK) and works with them to help support people living with PH and raise awareness.

Statement: People around the world are waiting too long to be diagnosed with the rare, incurable heart and lung condition of pulmonary hypertension (PH) because its symptoms are often mistaken for other diseases. Its rarity and the ‘invisible’ nature of its symptoms also mean that the public do not understand how serious PH is, making life harder for those who live with it and so to help to understand PH, the author has started online awareness campaigns to help those with PH live an ‘ordinary life’.

Methodology & Theoretical Orientation: To help the public and medical professionals to understand what we have to deal with every day, the best way to reach these people is through social media channels, such as Facebook, Twitter, YouTube and Instagram.

Findings: My awareness campaigns have caught the attention of many people around the world who either have PH, don’t know what it is, or have not heard of it. People have been coming forward to speak out about having PH and it is helping them to understand their condition. Those who do not know about PH have contacted me to say they have learnt a lot from my awareness campaigns.

Conclusion & Significance: Sadly, PH will probably always exist as a condition but with the awareness that I, and others, are generating on social platforms, I believe that one day it will be understood and diagnosed sooner. I also hope that with people coming forward and taking part in medical research, thanks to the awareness campaigns, one day a cure will be found.