8th King's John Price Paediatric Respiratory Conference

Introduction and Objectives Asthma is common but often misdiagnosed, especially when relying on clinical assessment alone. Spirometry, bronchodilator reversibility and fractional exhaled nitric oxide testing are objective recommended tests to confirm diagnosis. However, access to these tests is not available in most healthcare settings and spirometry is often normal when the patient’s asthma is stable. Peak expiratory flow rate (PEFR) measurements are inexpensive and widely available but there is currently insufficient evidence to support its use in the asthma diagnostic pathway, except as a 2-week peak flow diary.

Aim: To conduct a systematic review to understand available literature on the usefulness of repeated peak expiratory flow rate measurements in making a diagnosis of asthma in children and adults over the age of 5 years.

Methodology To conduct a systematic review to investigate the diagnostic value of repeated PEFR measurements in the asthma diagnostic pathway. We constructed search strategies to conduct a systematic review of the available literature. This produced a library of relevant clinical studies from January 1946 to December 2021 from the MEDLINE, COCHRANE, EMBASE, EMCARE and CINAHL databases. This systematic review will include randomised controlled trials, cohort studies, systematic reviews and meta-analyses which explore the diagnostic accuracy of repeated PEFR measurements in identifying children with asthma. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) will be used to evaluate the methodological quality of selected studies. A narrative synthesis will be conducted if a meta-analysis is not possible because of heterogeneity.

Results Our search strategy yielded 2079 studies from MEDLINE, 878 from COCHRANE, 830 from EMBASE, 151 from EMCARE and 69 from CINAHL. Title and abstract screening is complete and yielded 94 articles for Full Text Review.

Conclusion • What practical strategies for using peak flows in clinical practice should we look for in the literature? • What pitfalls should we explore? • Are peak flow meters available in primary care in low resource settings?

PROSPERO registration: 272922

Authors: Pooja Devani, Luke Daines, Norita Hussein, EE Ming Khoo, Rizawati Ramli, Steve Fowler, Hilary Pinnock, Erol Gaillard

Erol Gaillard

University of Leicester, Paediatric Respiratory

Ross Thomas

Sanofi & Regeneron Pharmaceuticals, Inc.

Ross Thomas

Sanofi & Regeneron Pharmaceuticals, Inc.

Angela Jamalzadeh

Royal Brompton Hospital

Introduction & objective: In March 2020, the way in which Respiratory Paediatric Clinical Nurse Specialists (CNS), supported by the wider MDT, were able to deliver and provide care for patients was dramatically curtailed due the COVID-19 pandemic. Our CNS team needed to adapt quickly away from the normal face to face care model whilst ensuring minimal compromise to patient care. There are several specialist CNS teams covering Cystic fibrosis (CF), Primary Ciliary Dyskinesia (PCD), Complex care, Non-Invasive Ventilation (NIV) and Difficult Asthma. Our objectives were i) to deliver care by resourcing and implementing a range of service adaptions and innovations ii) to collect patient feedback on these innovations. Method: Service adaptions and innovations implemented by the CNS team alongside the wider MDT are summarised in the table. A range of qualitative patient questionnaires utilising online platforms such as data collection tools were used to obtain feedback. Results: Feedback from parents / carers using a range of surveys focusing on specific innovations amongst different patient groups has shown a positive response to service adaptations. Less time missed off school, reduced travel times to attend appointments and improved convenience for families were common themes. Patients reported the home spirometry service and sampling services useful. Overall, most patients did not feel their respiratory care was compromised and a hybrid solution of face to face and virtual monitoring would be their preference going forward. Most of these changes have been adopted into our continued routine practice including home spirometers still being used for clinics. The postal sampling for microbiology and other tests has been rolled out across the hospital. Conclusions: Adaptions developed in response to the COVID-19 pandemic have been shown to be positive for patient experience.  A hybrid approach is likely to be the on-going future of Respiratory CNS service delivery. Two years since the onset of the pandemic many of the changes to our services and innovations are still in place. Follow-up questionnaires would be useful in determining ongoing satisfaction. However, further work needs to be done to look at long-term outcomes of our patients to confirm adequacy of this model of care.

Pippa Hall <p.hall@rbht.nhs.uk>

Royal Brompton Hospital

Introduction: EGPA is a systemic necrotizing vasculitis that affect small to medium sized vessels. It is a rare disease and can present as eosinophilic asthma. There are no specific diagnostic criteria. It can be challenging to diagnose Anti-neutrophil cytoplasm antibodies (ANCA) negative EGPA. We are presenting a case of ANCA negative EGPA that was initially treated as severe asthma.

Aim: To highlight a rare condition that if diagnosed early and treated optimally can increase the patient’s life expectancy and decrease associated comorbidity.

Description: A 7-year-old boy with severe recurrent wheeze transferred to our tertiary respiratory unit for specialist advice. He was on Seretide 125, 2 puffs BD via Volumatic, Cetirizine 5 mg once daily, Montelukast 5 mg once daily and Salbutamol 2-6 puffs via MDI and spacer. Despite maximal treatment he had recurrent hospital admissions and a multiple repeated courses of oral prednisolone. His FEV-1 was significantly reduced (35%). In clinic, he was noted to have lost 1kg in 6 weeks and to have significant back, shoulder and abdominal pain. He was admitted acutely for monitoring and investigations. Multiple specialities were involved in the diagnostic workup, (including rheumatology, oncology, cardiology, surgery, haematology, respiratory and general paediatric teams.) His CXR revealed patchy consolidation in the right perihilar region extending into the middle lobe. His initial Abdominal USS was normal, but the repeat USS viewed splenomegaly measuring 9cm in length. During admission, he had a swollen tender left scrotum. The USS suggested vasculitis/ischaemia and the surgical exploration confirmed torsion of the testicular appendix His blood results showed persistent significantly high eosinophilia, (add number) raised WCC, raised LDH and slightly high Inflammatory markers. His liver and renal screens were normal. His rheumatoid and connective tissue disease work up were negative (ANA, ANCA, IG and anti CCP).Malignancy was considered as a possible cause; however, cell markers and bone marrow slide were negative. His IgG for Aspergillus Fumigatus was negative. In view of recurrent wheeze, weight loss, abdominal pain and very high eosinophilia, EGPA was suspected. The CT chest showed pericardial and pleural effusion with scattered parenchymal lung nodules and small volume bilateral hilar lymphadenopathy supporting a diagnosis of EGPA. He improved on IV methylprednisolone and IV co-amoxiclav.

Conclusion: The initial presentation of EGPA can mimic severe asthma and it is associated with blood and tissue eosinophilia. One should consider EGPA in patients not responding to maximal asthma therapy, especially if there are any additional systemic signs. Other causes of reactive eosinophilia should be excluded such as Aspergillus, parasites and leukaemia. Detecting pulmonary infiltrates on CT scan with extrapulmonary vasculitis signs helped aid the diagnosis. High dose glucocorticoid therapy is the treatment of choice to achieve remission. Immunomodulators can be considered in relapse.

References: 1- Matthieu Groh, et al. Eosinophilic granulomatosis with polyangiitis (Churg–Strauss) (EGPA) Consensus Task Force recommendations for evaluation and management, European Journal of Internal Medicine, Volume 26, Issue 7, 2015, Pages 545-553, ISSN 0953-6205, https://doi.org/10.1016/j.ejim.2015.04.022. Accessed on 15/03/2022

2- Sokolowska, Barbara M., et al. ANCA-positive and ANCA-negative phenotypes of eosinophilic granulomatosis with polyangiitis (EGPA): outcome and long-term follow-up of 50 patients from a single Polish center. Clin Exp Rheumatol 32.3 Suppl 82 (2014): S41-S47. Accessed on 18/03/2022

Eman Hassanin

Leeds Children’s Hospital. Department of Paediatric Respiratory Medicine

Are we failing in the respiratory management of children with neurodisabilities and complex respiratory diseases? A review of paediatric respiratory physiotherapy practice and microbiology management in children and young people with Neurodisabilities and respiratory morbidity in Edinburgh, East and Mid Lothian.

Zoe Johnstone <zoe.johnstone@nhslothian.scot.nhs.uk>

Royal Hospital for Children and Young People Edinburgh

Introduction & objectives: Dysfunctional breathing is a commonly recognised condition in adults but prevalence within Children and Young People (CYP) remains unclear (de Groot 2013). Distinguishing it from other conditions (e.g. asthma) in the absence of an agreed definition is difficult. Currently diagnosis is made following exclusion of other causes. However symptoms and outcome measures are generally based on adult data which are not always synonymous with the experiences of CYP. The literature has also highlights a lack of confidence in clinicians to diagnose DB (Pedersen et al 2021)and consequently the time from symptoms occurring to treatment can be protracted. Obtaining a better understanding of which criteria experienced clinicians consider most accurate in identifying DB in CYP may reduce misdiagnosis, reduce the use of unnecessary medication and improve quality of life. Objective: To achieve an agreed definition of dysfunctional breathing & symptoms specific to CYP. Methods: An e-Delphi survey was conducted with paediatric respiratory experts across the UK: medical, nursing & physiotherapy with >5 yrs experience. A structured questionnaire based on current literature findings was used to identify the relative importance of main clinical features and descriptions to reach an agreement on the definition of this combination of symptoms. Consensus was defined in advance at 75% and 3 rounds were undertaken, improving consensus at each round. Results: 39 participants were recruited and 30 respondents completed all 3 rounds. ‘Dysfunctional breathing’ continues to be most commonly used as an over-arching term encompassing breathing pattern disorder, inducible laryngeal obstruction & vocal cord dysfunction. Agreed key clinical features were breathlessness, chest or throat tightness, difficulty breathing in, anxiety and a sensation of air hunger. Interestingly subsequent analysis highlighted that, when compared with other clinicians, physiotherapists placed greater emphasis on frequent yawning and frequent sighing as important symptoms of DB in CYP. Conclusion: A multidisciplinary Delphi panel delivered a high level of agreement on the definition & clinical features specific to CYP with DB. Hopefully this will better inform clinicians and support the development of an accurate screening tool to enable more timely intervention in future. References De Groot, E., Duiverman, E. & Brand, P. (2013) Dysfunctional breathing in children with asthma: a rare but relevant comorbidity. Eur Respir J. 41 (5): 1068-73. Pedersen, E., Ardura-Garcia, C., de Jong, C., Jochmann, A., Moeller, A., Mueller-Suter, D., Regamey, N., Singer, F., Goutaki, M. & Kuehni, C. (2021) Diagnosis in children with exercise‐induced respiratory symptoms: Pediatric Pulmonology. 56:217–225.

Ruth Stewart

Royal Hospital for Children and Young People, Edinburgh

Background: Omalizumab binds to IgE, blocking IgE binding to it’s receptor, preventing an inflammatory response. It has shown a good safety and tolerability profile in children with severe asthma. However, little is known on the long-term effectiveness of omalizumab in children and adolescents in real life settings, or any factors identified to predict which patients respond.

Aims: To investigate if omalizumab provides long-term, sustained effectiveness by maintaining good asthma control defined as ≤2 oral steroid (OCS) courses in one year and/or an ACT≥ 20 for its duration and whether any markers can reliably predict effectiveness.

Methods: A multi-centre case note review of children (aged <18 years) commenced on omalizumab for persistent allergic asthma. Demographic, ACT, total and specific IgE, eosinophils, spirometry (FEV1, FeNO), and exacerbation history were collected at baseline and at 4 monthly intervals (excluding IgE and eosinophils).

Results: 79 patients, 42% male, with a mean age of 11.6 years (5-17 years) were included. The mean IgE at baseline was 1000 (57-1300). The total mean daily ICS dose equivalent to fluticasone propionate was 617mcg (400-1000). 37 patients (47%) were receiving daily oral steroids at baseline. Mean ACT at baseline was 12. The follow up ranged from 4-84 months. In the first year 14 patients discontinued; 9 due to poor efficacy, 1 due to needle phobia, 3 unclear reasons and one due to urticaria. One patient was lost to follow up and 3 moved to different centres.

At one year 17 patients were still receiving daily oral steroids, reducing to 9 patients by 24 months, and only one at 84 months. Mean daily ICS dose did not materially change over the follow up period. Courses of OCS for exacerbations fell from a median of 6 in the 12 months pre omalizumab to 1 during the first 12 months post omalizumab. Mean ACT increased from 12 at baseline to 18 at 12 months. Only 46% of patients receiving omalizumab at 12 months reached our definition of “well controlled”. There was little change in overall FEV1. FeNO values did reduce from a mean of 54 ppb at baseline but remained with a mean of >25ppb. Baseline FeNO, specific IgE or eosinophil count did not predict achieving “well controlled” asthma, either overall or when adjusted for ICS dose.

Conclusion: Omalizumab improved asthma control in approximately half the patients, and most on OCS were able to stop over time, but many patients still remained sub optimally controlled. Other variables in addition to high total IgE are likely to influence asthma control.

Dr Elizabeth C Gregson

Sheffield Children's Hospital NHS Foundation Trust, Manchester University NHS Foundation Trust, Kings College Hospital NHS Foundation Trust, Bradford Teaching Hospitals NHS Foundation Trust

I'll be back! - Children who reattend the ED with wheeze / asthma Richard Chavasse St George's University Hospitals NHS Foundation Trust Mohammed Al-Wasity

Introduction & Objectives Recurrent asthma / wheeze is a common reason for children and young people (CYP) to attend the emergency department (ED). We aimed to see whether similar risk factors were shared between pre-school and school aged CYP who had multiple admissions and to see whether targeted care might be feasible to reduce readmissions.

Methods All CYP attending the ED at St George's hospital are identified by the Asthma CNSs and recorded on a database. We identified all CYP who were admitted to the ward or paediatric assessment unit (PAU) on three or more occasions between 2017-2019 to try and identify factors that may highlight children at risk. Age, sex, ethnicity, smoke exposure, atopic disposition and index of deprivation based on postcode were assessed along with treatment in place at the subsequent clinic review.

Results We recorded 3550 ED attendances with wheeze / asthma leading to 2556 admissions in the study period. From this 149 children had three or more attendances accounting for 597 admissions (24%). Of these, 122 (82%) were 1-5 years of age. Other factors are described in the table. In approximately 2/3, the three attendances occurred within 12 months while the remainder had admissions spread across more than one year. At review in clinic, 63% of <5's and 80% >5's had been prescribed inhaled corticosteroids. 1-4 yrs 5-17 yrs Number 122 27 Gender (%male) 65 % 52% Number of admissions 448 149 3 / 4 / 5+ 71 / 33 / 18 7 / 2 / 18 Ethnicity White / Black / Asian / Mixed (%) 45% / 8% / 27% / 7% 21% / 44% / 15% / 11% Atopic History (+ve) 60% 78% Tobacco Exposure (+ve) 25% 29% Index of Deprivation Decile 0-5 42% 40% Index of Deprivation Decile 6-10 57% 60%

Conclusions Preschool children comprise the majority of patients. Typically the majority are male, White or Asian compared to the older cohort where Black CYP seem over-represented. The majority of CYP, even in the younger group had an atopic history supporting the use of ICS. Surprisingly, the deprivation scores did not identify this as a risk factor. The older cohort identify a group of poorly controlled asthmatics despite regular clinic review. We will use this information to help identify CYP at risk of readmission. References Recurrent wheezing in the first three years of life: short term prognosis and risk factors. J Asthma, 2013 vol 50(4):370-5. Sahiner, UM et al.

Richard Chavasse

St George's University Hospitals NHS Foundation Trust, St. George's University of London

Many pharmacological studies of asthma drugs - including recently developed biologic treatments for asthma - have been studied in cohorts that over-represent White children. We measured the proportion of participants in registered clinical trials relating to paediatric or adolescent asthma over the last decade that were from White and non-White backgrounds. Of 112,327 patients, almost 69% (77,333) were described as White or Caucasian, and fewer than 13% (14,189) were described as Black, African, or African-American. Children from ethnic minority groups have a lower participation rate in studies, and therefore important differences in treatment outcomes may be overlooked in research trials.

Adam Lawton

North Middlesex NHS Hospital Trust, Surrey And Sussex Healthcare NHS Trust, Royal London Hospital, Barts Health NHS Trust, Department of Paediatric Respiratory Medicine, King's College Hospital, London

Background: Regular reviews of children with asthma are essential to ensure adherence to medication and correct use of delivery devices. Any medication changes made in hospital clinics should be continued in primary care. Transfer of information about medications across care boundaries can be challenging; between 30 and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred1.

Objectives: i) To determine whether medication changes made in a tertiary hospital asthma out-patient clinics are continued in primary care and ii) to explore parents/carers experience on medicines optimisation across care boundaries.

Methods: Mixed-methods service evaluation using qualitative and quantitative methods. Electronic patient records were used to identify children who had medication changes made in clinic between September-November 2020 and to see if this change was reflected on GP summary care records (SCR) three months later. Telephone interviews using semi-structured questionnaires were conducted with parents/carers of children in whom medication changes had been made in an out-patient clinic in a tertiary paediatric asthma centre, exploring their experiences and categorized into themes.

Results: See fig 1 - consort flow diagram of patients. 52% (12/23) of changes were accurate on SCR records, 35% (8/23) of changes were inaccurate and in 13% (3/23) no changes appeared on SCR.

Patient’s responses in the interviews were grouped into themes: 1. Medication supply issues: “The GP surgery couldn’t find the clinic letter that had been sent to them, so he missed a couple of days of his inhalers whilst we sorted out the issue”

2. Improvements in transfer of care: “You can never have too much communication” “It would be useful to have someone else looking out for the medication changes just in case the GP misses it. I don’t always remember correctly either.”

Conclusions Medication changes made in out-patient clinics are either not transferred accurately or no changes appear in primary care records nearly 50% of the time. Better communication between care providers is required for more effective care.   Fig 1: Consort flow diagram of patients.

References: 1. National Patient Safety Agency and National Institute for Health and Clinical Excellence. Technical safety solutions, medicines reconciliation. 2007 www.guidance.nice.org.uk/PSG001

Sukeshi Makhecha

Royal Brompton Hospital

The fall and rise of asthma admissions (in the COVID era)

Richard Chavasse St George's University Hospitals NHS Foundation Trust

Introduction & Objectives The number of children presenting to hospital fell dramatically during the national lockdowns in 2020 and 2021 used n response to the SARS-Cov-19 pandemic (1). The reasons for this were subject to conjecture but included a reduction in respiratory viral transmission, delayed presentation, increased adherence and an improvement in air quality. The most likely factor being the reduced spread of respiratory viruses due to reduced contact with social distancing, attention to hand hygiene and the use of face masks. We have continued to track hospital admissions of children with asthma to understand .whether changes in lifestyle have continued to protect children with asthma.

Methods The children's asthma nurses at St George's Hospital record all children admitted with asthma on a daily basis. We compared the average monthly admissions between 2017-9 with those in 2020 through to 2022.

Results The attached graph shows the variation in admissions on a monthly basis. Pre-covid typically there were approximately 1 admission per day between January to June before reducing in the summer, followed by a spike in September to December. In 2020 admissions were almost completely abolished from April to Jul during the first national lockdown and significantly reduced in January to February 2021 during the second lockdown. The 2021 September spike was present but muted. In later 2021 there was evidence of an earlier autumn spike starting in August with a significant increase from previous years through September and October with over 2 admissions per day.

Conclusions The impact of the National Lockdowns showed that reduced viral transmission in school aged and preschool children reduces the number of children admitted with wheeze. Sadly the practices to reduce viral transmission including face masks, improved hand hygiene and social distancing have not been continued and we have reverted to previous poor practices. The lessons from the pandemic have not been learnt. Improvement in classroom environment (ventilation) and improved adherence to methods to reduce viral transmission should be encouraged and introduced as good practice.

References 1. The indirect impact of COVID-19 on children with asthma. Arch Bronconeumol 2020;56(11):768-9. Chavasse R et al.

Richard Chavasse

St George's University Hospitals NHS Foundation Trust

Introduction and Objectives Nebulised Magnesium Sulphate (MgSO4) has been introduced as a recommendation in the treatment of acute asthma in secondary care1, however the evidence for this is varied, showing modest, non-significant benefits in most cases, with most benefits seen in those with severe symptoms2,3. The aim of this study was to determine if, and when nebulised MgSO4 was being given to children presenting with either Viral Induced Wheeze (VIW) or asthma exacerbations in a District General Hospital in the East of England. Furthermore, to determine whether early MgSO4 use shortened hospital stay for these children.

Methods All paediatric patients presenting to the Emergency Department or Children’s Assessment Unit with a diagnosis of VIW or asthma between October-December 2020 were identified. Those staying in hospital for >8 hours were isolated, and the notes examined. They were split into groups depending on age (2-5 years, and >5 years) to determine severity (mild/moderate, severe, and life-threatening) as per the British Thoracic Society (BTS) classifications1. Drug charts were used to see whether patients received nebulised MgSO4, and if so, how long after initial presentation. Finally, length of stay (LOS) was compared with MgSO4 use and the timeline in which it was given.

Results 51 children >2 years were admitted with the above criteria. 8 (16%) were classified as mild/moderate, 40 (78%) were severe, and 3 (6%) were life-threatening. 1 (12.5%) patient with mild/moderate asthma received MgSO4, 19 (47.5%) patients with severe asthma received MgSO4, and all those with life-threatening asthma received MgSO4. The average LOS for patients who did not receive MgSO4 was 19.2hrs, patients receiving MgSO4 in the first hour was 29.4hrs, patients receiving it in 1-3.9hrs was 26.2hrs, patients receiving it in 4-7.9hrs was 22.5hrs, and patients receiving it >8hrs from presentation was 35.5hrs.

Conclusion Early administration of nebulised MgSO4 does not appear to shorten hospital stay, however MgSO4 given >8 hours since presentation is associated with longer hospital stays. These findings may be confounded by the fact that children who are more unwell, and thus more likely to have a prolonged stay, are likely to receive MgSO4 earlier.

Marian Michael

Lister Hospital, East and North Hertfordshire NHS Trust, Department of Paediatrics

Introduction & Objectives: The impact that the NHS has on the environment is huge. The carbon dioxide emissions from the NHS account for more than all flights leaving Heathrow each year. One of the biggest contributors of carbon emissions are medicines, which account for 25% of the overall carbon footprint. Inhalers make up 3.1% of this. It is the hydrofluorocarbon propellants in inhalers which produce carbon dioxide. By switching from metered dose inhalers (MDIs) to dry powdered inhalers (DPIs), the amount of CO2 released into the atmosphere can be reduce by 25 times per actuation.

This study aimed to highlight the impact that our prescribing practices for children with asthma at Leeds Children’s Hospital (LCH) have on the environment. Our primary objective was to increase the number of children in our tertiary asthma clinics who were prescribed DPIs as their preventer inhaler. Our secondary objective was to highlight how we dispose of inhalers and encourage the use of one puff over two puffs to achieve the same dose.

Methods: All patients aged 8-16 years who attend the tertiary asthma clinic at Leeds Children’s Hospital were included in the study. Those who had an alternative diagnosis, poor lung function (FEV1 <75%) or significant co-morbidities which would make them unable to co-ordinate a forceful inhalation were excluded.

We planned a training programme for staff and families, displayed posters and added a section to the asthma clinic proforma to encourage switching to DPIs.

Results: 224 patients were identified, of these 26 were excluded based on the exclusion criteria. Of the 198 included, 122 were suitable to switch to a DPI, 45 were already on a DPI and 31 were not appropriate based on their clinical condition. With respect to acute Salbutamol prescribing, 2,973 Salbutamol MDIs were prescribed in LCH in 2021 (Paediatric A&E and inpatient paediatric wards). This is the equivalent carbon dioxide emissions of 520,275 miles of driving.

Conclusions: There is a huge scope for reducing the carbon footprint asthma inhalers have on the environment by changing our prescribing practices, disposing of inhalers effectively and encouraging families to only replace their inhalers when they need to.

Dr Andy Brookes

Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust

Introduction & Objectives

Episodes of acute wheeze comprise a significant proportion of unplanned paediatric hospital admissions in the UK. The UK has amongst the highest asthma-related mortality rates in Europe, and emergency admissions correlate with socio-economic deprivation within populations(1). The National Review of Asthma Deaths in 2014 concluded that most asthma-related morbidity & mortality is preventable with the implementation of basic care interventions, such as timely follow-up and the use of personalised asthma plans(2). However, basic asthma care levels across the UK are poor(2). A local audit identified wide variation in discharge practices in our Trust for children admitted with wheeze, which was not always consistent with BTS/SIGN guidance(3,4). BTS/SIGN considers episodes of acute wheeze ‘failure(s) of preventive therapy’, and an opportunity to ‘avoid further severe episodes’(4). We attempted to utilise acute admissions as opportunities to improve basic care, via the initiation of a standardised discharge pathway for all children aged ≥1 year admitted with acute wheeze, which aligned with BTS/SIGN standards.

Methods

A retrospective study of electronic patient records of all children admitted with acute wheeze to a large, inner-city teaching hospital during November 2020 was performed, to characterise baseline discharge practises. A standardised discharge proforma was then designed (fig. 1), which aligned with BTS/SIGN discharge guidance(3). Proforma completion was made mandatory for all children ≥1 year of age admitted with acute wheeze, regardless of diagnosis (i.e. viral-induced wheeze vs asthma). This was introduced in June 2021 and was supported with staff education sessions, and the case notes of children admitted in November 2021 were re-audited post-intervention.

Results

28 children were admitted in November 2020 with acute wheeze, and 37 children were admitted post-intervention in November 2021. Results pre & post-intervention are summarised in figure 2. Post-intervention, approx. 40% more patients were reviewed by the asthma team in hospital, and approx. 60% more children were provided with a written personalised asthma plan. The first audit cycle identified variable practice in advice given regarding salbutamol use at discharge. Local guidance was changed in line with GINA recommendations(5), and post-intervention, the use of salbutamol weaning regimes fell by ~85%.

Conclusions

Implementation of a standardised discharge bundle for acute wheeze improved compliance with BTS discharge guidance, in all areas measured, with the caveat that pre-intervention practice may have been influenced by the Covid-19 pandemic. Our expectation that this significant increase in clinical workload will translate into better outcomes (e.g. reduced exacerbation/admission rates, improved symptom control), and we plan to examine this in future.

References

1. State of Child Health, RCPCH, 2020 2. NRAD Confidential Enquiry report. RCP, 2014 3. BTS Asthma Discharge Care Bundle: 2016, BTS, 2016. 4. BTS/SIGN Guideline for the Management of Asthma 2019, BTS/SIGN, 2019 5. Global Strategy for Asthma Management and Prevention, GINA, 2019

Dr Laura White, ST7 Paediatrics

King's College Hospital NHS Foundation Trust

Montelukast-associated neuropsychiatric side-effects in tertiary paediatrics: a qualitative interventional study into awareness and prescribing practices

Samantha Flowers, Eleanor Minshall Sheffield Children's NHSFT

Introduction & Objectives

Montelukast has been linked to severe neuropsychiatric side effects1, prompting a recent government drug safety update2. Prescribing clinicians and patients/carers may not always recognise that serious side effects can be linked to the drug. The aim of this study was to evaluate clinicians' awareness regarding the side effects of Montelukast and to ascertain whether they are appropriately counselling patients/carers when prescribing. Our hypothesis was that awareness and counselling would be sub-optimal and that we could improve prescribing practices through education.

Methods

An anonymous qualitative questionnaire, based on the recent drug safety recommendations, was sent to 51 clinicians in a tertiary paediatric children’s hospital. Those completing the questionnaire (n = 20) were then sent further educational information on Montelukast. Six months later, the questionnaire was resent to reassess their awareness of the side-effects and any change in their prescribing practices (n = 9 respondents).

Results

Most of the respondents were prescribing Montelukast at least once a month. The vast majority (95%) were initially aware of the three broad categories of neuropsychiatric side effects (sleep disturbance, behaviour and mood changes). Over half (50-70%) were warning patients regarding these categories. After the educational material was sent, their awareness increased to 100% for sleep disturbance and behaviour changes and was associated with an increase in counselling regarding all three main categories. The most noticeable improvement was for change in mood (50% initially; 78% after 6 months).

Depression and suicidal thinking/behaviour were initially under-appreciated as significant side-effects (45% awareness for both) but this improved (78% and 67% awareness respectively) following the educational material. The percentage of clinicians warning about depression, and suicidal thinking/behaviour also increased following the educational material (25% and 20% initially to 67% and 44% respectively). Most clinicians were advising patients/carers to seek medical advice for neuropsychiatric concerns, and this increased in the follow up questionnaire (67% to 89%).

Conclusions

Not all clinicians experienced in prescribing Montelukast are aware of potential neuropsychiatric side-effects. Knowledge of significant side-effects was sub-optimal, risking children’s well-being and mental health. Educational materials did improve clinicians’ knowledge and behaviour regarding prescribing practice. Further research/training is needed to address this important safety concern.



References

Ernst P and G Ernst. Neuropsychiatric adverse effects of montelukast in children. Eur Respir J 2017; 50: 1701020

Montelukast (Singulair): reminder of the risk of neuropsychiatric reactions. https://www.gov.uk/drug-safety-update/montelukast-singulair-reminder-of-the-risk-of-neuropsychiatric-reactions

Dr Samantha Flowers

Sheffield Children's NHSFT

Introduction The pathophysiology of acute airway obstruction underlying the symptom of wheeze in the preschool age group is heterogeneous. Eosinophilic airway inflammation is implicated in a proportion, and daily inhaled corticosteroids can provide effective symptom control in children with a peripheral eosinophil count >300 cells/µL1. However, the use of oral corticosteroids to treat acute wheeze attacks in the preschool group as a whole is ineffective. Despite this the treatment of children admitted to hospital often includes oral corticosteroids2. We hypothesised that preschool children with peripheral eosinophilia admitted with acute wheeze would show a differential response to treatment with oral corticosteroids as indicated by length of stay. Methods Children admitted between 1st January and 31st December 2021 with acute wheeze, and aged between 12 and 60 months were identified. Those children who had a peripheral eosinophil count on admission and received treatment with oral corticosteroids were selected. Length of stay was calculated as the time between treatment initiation and decision to discharge. Children were divided into two groups; those with an eosinophil count above 300 cells/µL (eosinophil high) and those below 300 cells/µL (eosinophil low). Comparisons were performed using Mann-Whitney U Test. Results 252 preschool children were admitted with wheeze. 82 children (median age 29 months, range 12-60) had an eosinophil count recorded on admission and received treatment with oral corticosteroids. 22/82 (26.8%) had an eosinophil count >300 cells/µL (median age 29 months, range 13-60). 60/82 (73.1%) had an eosinophil count <300 cells/µL (median age 29 months, range 12-60). The median length of stay was not significantly different for the eosinophil low group, median stay 41.5 hours (range 14-204.5); and the eosinophil high group, median stay 46.75 hours (range 21-251) (p=0.089).   Conclusion There was no significant difference in the length of stay of preschool children admitted with acute wheeze and treated with oral corticosteroids as determined by blood eosinophil count. The eosinophil high group was small thus a type one error cannot be excluded. Identifying larger cohorts, and comparisons of length of stay including children not treated with oral corticosteroids in both eosinophil high and eosinophil low groups maybe helpful.

Junaid Manzoor

King’s College Hospital, Denmark Hill, London, UK

Supriya Shinde <supriyasureshshinde@gmail.com>

University Hospital Southampton NHS Trust

Introduction and Objectives:

Paediatric non-cystic fibrosis bronchiectasis (NCFB) can present with a multitude of symptoms and underlying disorders (1, 2). This study aims to identify potential clinical phenotypes and risk factors for NCFB in children presenting to one tertiary respiratory hospital in London.

Methods:

Children diagnosed with NCFB in a tertiary respiratory hospital were reviewed in terms of their demographics, microbiological profile, lung function and hospital admissions. Patients with primary ciliary dyskinesia were excluded. Statistical analysis was conducted using SPSS.

Results:

We evaluated 24 paediatric NCFB patients [(16 male, 67%) with mean age: 11.7, SEM 0.8], from eight ethnic groups. The most commonly associated conditions included: gastroesophageal reflux (n=14, 58%), atopy (n=9, 38%), dysphagia (n=8, 33%), airway malacia (n=5, 21%), immunodeficiency (n=5, 21%) and post tuberculosis (TB) (n=3, 12.5%). Hospital admissions were used as a marker of severity of exacerbations, and only 10 patients (41.6%) required an inpatient stay between 2021-2022.

Overall, our cohort of patients maintained good lung function [FEV1 % of predicted normal value: mean 89.1, SEM 4.4 – two patients excluded from analysis as they were unable to perform spirometry]. Staphylococcus aureus was the most common pathogen isolated in sputum cultures (n=8, 33%) and 21 patients (88%) were on prophylactic azithromycin. No statistically significant association was found between FEV1 or number of hospital admissions in the last year and age, gender, ethnicity, or any of the most common comorbidities.

Conclusions:

The population analysed represents a heterogeneous group of children, with overall good lung function. None of the potential risk factors analysed were statistically associated to FEV1 or the number of hospital admissions. Most patients had co-morbidities commonly described for NCFB, including post-TB (1, 2). Limitations of this study include the small sample size and the imposition of COVID restrictions during the analysis period, which may have reduced these children’s exposure to the usual pathogens which contribute to infective exacerbations. Future analysis will be useful to compare the difference in hospital admissions post COVID restrictions, success rate of rescue antibiotics at home in preventing hospital admissions, and adherence to physiotherapy regimes in maintaining good lung function.

References:

1. Brower KS, Del Vecchio MT, Aronoff SC. The etiologies of non-CF bronchiectasis in childhood: a systematic review of 989 subjects. BMC pediatrics. 2014;14(1):1-8.

2. Chang AB, Bush A, Grimwood K. Bronchiectasis in children: diagnosis and treatment. The lancet. 2018;392(10150):866-79.

Kushalini Hillson

(1) Paediatric Respiratory Medicine, Royal London Hospital, Barts Health NHS Trust (2) Queen Mary University, London.

Laryngeal web is a rare malformation. It may appear at any age with a hoarse or weak voice and frequent respiratory infections. We report a 3-year child with a history of respiratory distress and high-pitched cry in infancy and recurrent skin infections. He had a recurrent glottic web for which he was operated twice. Delayed separation of the umbilical cord and absence of pus formation at the sites of skin infection was also present. It is a hallmark of leucocyte adhesion defects. These phagocytic cell deficiencies range from mild to recurrent skin infections. Laryngeal web with primary immunodeficiency is a rare association. Keywords: Laryngeal web, Primary Immunodeficiency

Dr Shetanshu Srivastava <drsitanshu@yahoo.co.in>

Department of Pediatrics and Neonatology, ENT. Dr RML Institute of Medical Sciences, Lucknow ,India

Over the past decade there has been an increase in the prevalence of children with life limiting conditions and complex needs (1). Inequalities and poor standards of care of individuals with disabilities have been highlighted in various reports. The number of patients under follow up with our paediatric respiratory multidisciplinary team (MDT) for children with severe neurodisability has increased in the past 3 years with a significant rise in those reaching transition age. We established a transition clinic jointly with adult respiratory services in 2018 in a large, tertiary hospital. Our aim was to identify gaps and areas of improvement in our transition process of children with complex needs under the care of our MDT clinic. 19 patients reached transition age between 2018 and 2021. The majority of patients had a diagnosis of cerebral palsy (61.5%). All patients had severe motor function impairment, required feeding via enterostomy and had a high number of co-morbidities. Burden of respiratory care was high, all patients were on nebulised medication, had regular respiratory physiotherapy, the majority were using suction at home (77%). All patients had input from community paediatrician. We identified a number of gaps with transition process which include no access to respiratory physiotherapy or specialist nurses, lack of pathways for equipment provision and maintenance. Greater reliance on general practitioners (GP) posed a challenge to both the GP and families. Highlighted areas for improvement were earlier involvement of GPs in transition process and increasing local clinical commissioning group engagement.

Laura Lowndes <laura.lowndes@addenbrookes.nhs.uk>

Cambridge University NHS Trust

Hannah Farley

Great Ormond Street Hospital

Introduction & Objectives Patients managed in the cardiothoracic Paediatric Intensive Care Unit (PICU) include those with congenital heart disease, cardiac failure, airway and respiratory disorders. There are few recent studies which represent this subgroup of patients. We describe experience from a quaternary cardiothoracic centre to better understand characteristics, indications for and outcomes of patients undergoing tracheostomy.

Methods Single centre retrospective cohort study of patients undergoing tracheostomy during admission to cardiothoracic PICU between 2017 and 2022. The Freeman Hospital is one of two UK centres which provides a quaternary paediatric cardiothoracic transplant service and mechanical support to those awaiting heart transplant. Electronic records were reviewed and data recorded included demographics, diagnosis, co-morbidities and outcome.

Results During the study period there were 1420 admissions. 40 (2.8%) patients underwent tracheostomy. Median age at tracheostomy was 560 days [IQR 152 – 2982]. 43% of patients were under 1 year of age at time of tracheostomy. 60% had a diagnosis of congenital heart disease, 32% had cardiomyopathy and 8% had primary respiratory disease.

36 patients (90%) underwent a procedure prior to tracheostomy. 29 patients (73%) received mechanical cardiac support during their admission (Extracorporeal Membrane Oxygenation (ECMO) or Ventricular Assist Device (VAD).

Indications for tracheostomy were multifactorial in 40% of patients. These included cardiac failure (60%), airway anomalies (40%), lung pathology (including diaphragmatic lesion) (27.5%), and critical illness myopathy (27.5%).

24 patients (60%) survived until hospital discharge. At time of follow up, 6 patients (15%) were surviving with tracheostomy, 19 (48%) were surviving decannulated, 15 (37%) died with tracheostomy in situ. No patients died following decannulation and there were no tracheostomy related deaths. Median duration of tracheostomy was 152 days [IQR 55 – 546].

Conclusions In cardiothoracic PICU tracheostomy is most often indicated to support long term ventilation for children with cardiac failure and is required more often than in non-cardiothoracic centres1. Many patients have multiple factors necessitating its use. It is difficult to identify predictive factors to determine insertion or duration, however the majority of patients who survive until discharge were later decannulated.

References 1. Powell J, Buckley HL, Agbeko R, Brodlie M, Powell S. Tracheostomy trends in paediatric intensive care. Arch Dis Child. 2021 Jul;106(7):712–4.

Deborah Cross

Freeman Hospital, Newcastle Hospitals NHS Foundation Trust

Supriya Shinde <supriyasureshshinde@gmail.com>

Manipal Hospitals and Bangalore Baptist Hospital, Bangalore, India

Longitudinal Change in Oxygen Desaturation Indices – Differences Between Term and Preterm Infants. Authors: L Sykes Macleod1, M Last1, P Crowley2, S Mckay2, P Lowe2, O Falconer2, H Evans2 1. University of Southampton 2. University Hospital Southampton NHS Foundation Trust

Background: Many preterm infants are born with immature respiratory systems and are regularly discharged on home oxygen1. Both hypoxia and hyperoxia are associated with side effects2. Therefore, guidelines concerning appropriate administration and weaning oxygen are essential. Currently, oxygen saturation reference ranges for neonates born after 32 weeks gestation are incomplete.

Aims: To observe changes in peripheral oxygen saturation indices over the first 5 weeks of life in infants born after 32 weeks gestation and how these indices differ between term and preterm infants.

Methods: Infants were recruited to the one of 2 groups: 32-36 weeks gestation (preterm) or 37-42 weeks gestation (term) prior to discharge from hospital. Overnight pulse oximetry recordings took place at home at 7, 14, 21, 28 and 35 +/- 3 days of postnatal age.

Results: Here we report preliminary data on 36 pulse oximetry recordings from 8 infants (4 preterm and 4 term) Peripheral mean oxygen saturations increased in both preterm from 95.1% (interquartile range 93.3%-96.5%) to 96.5 (96.1-96.6%) and in term infants from 94.4% (93.8%-95.0%) to 96.6% (95.1%-97.6%) during the period of study. The number of oxygen desaturations ≥4%/hour from baseline (ODI4) were measured. Preterm infants displayed an increase in ODI4 from week 1 to 2 from 26.3 (21.9-38.4) to 41.3 (27.1-58.9), before then falling to 23.9 (16.9-29.1) in week 5. Term infants did not demonstrate this rise in desaturations, instead the ODI4 progressively declined from 56.4 (41.3-71.5) to 17.7 (12.4-27.5).

Conclusion: This preliminary data suggests that preterm infants are affected by deep transient desaturations that increase in severity over the first 2 weeks of life before gradual resolution, which is not seen in term infants. We hypothesise that this reflects greater vulnerability to increased metabolic demands in the postnatal period which is exacerbated by smaller functional residual capacity in preterm infants. The study is ongoing and aims to define patterns and reference ranges for oxygen saturation parameters across the moderate-late preterm and early term infant spectrum.

References: 1. Balfour-Lynn IM, Primhak RA, Shaw NJ. A review of the specific requirements of home oxygen therapy in children which attempts to offer guidance to clinician and service providers. Thorax 2005;60:76-81. 2. Askie LM, Darlow BA, Davis PG, et al. Effects of targeting lower versus higher arterial oxygen saturations on death or disability in preterm infants (Review). Cochrane Database of Systematic Reviews 2017;4:CD011190.

Olivia Falconer

University Hospital Southampton NHS Foundation Trust and University of Southampton Medical School

Introduction: Home pulse oximetry (HPO) can be used as a screening tool for obstructive sleep apnoea in children with trisomy 21. Previous studies1,2 have demonstrated significant night-to-night variability. We aimed to determine cut-off values to predict the likelihood that respiratory indices on night one would change over subsequent nights.

Methods: Children with trisomy 21 over the age of 12 months were recruited between April 2020 and March 2022 to attend HPO over three consecutive nights. Studies containing night recordings with less than 4 hours artefact-free recording time (AFRT) were excluded from the analysis. Pre-determined clinically relevant cut-off (CRCO) values - mean oxygen saturations (SpO2) <94%, Oxygen Desaturation Index 4% (ODI4%) >4, Oxygen Desaturation Index 3% (ODI3%) >6 and delta 12s index (D12) >0.55 - were used to identify cases of change (COC), defined as: values that fluctuated above and below the CRCO values across nights one to three. Receiver-Operator Curve (ROC) analysis was used to determine cut-off values with the optimum sensitivity and specificity to predict likelihood of becoming COC over subsequent nights.

Results: 47 children aged 1.6 to 15.7 years (median 5.5 years) underwent 60 HPO studies over the study period. 13 studies were excluded due to insufficient AFRT on at least one night and 11 failed to complete three nights due to equipment failure or user error, leaving 36 complete studies for analysis. The median SpO2 for the cohort was 95.7% (91.5–98.8). The proportion of COC across nights one to three were as follows: mean SpO2 =17% (6/36), ODI4% =47% (17/36), ODI3% =39% (14/36), D12 =36% (13/36). A meaningful upper limit for D12 could not be determined due to large variability. There were no COC for studies with mean SpO2>94% on night one (NPV 100%).

Conclusion: The high proportion of COC within the respiratory indices corroborates existing reports of night-to-night variability in these children. NPVs for ODI4%<2.74, ODI3%<3.70, D12<0.475 and mean SpO2>94% were 83%, 100%, 100% and 100% respectively, suggesting these values are unlikely to cross these cut-offs over subsequent nights. When obtaining complete three-night HPO studies is challenging, predicting COC after a single night of HPO may help inform whether further investigation via cardiorespiratory sleep study is warranted.

Jonathan Ong

University Hospital Southampton NHS Foundation Trust

Introduction There is limited evidence about the role of pulmonary function testing in the diagnosis and management of children with tracheobronchomalcia (TBM), which causes airway obstruction. What evidence is available primarily involves techniques which are either invasive or require significant patient co-operation, e.g. sedated VmaxFRC, spirometry. TBM may cause bronchodilator unresponsive wheeze. Beta 2 agonist use has been demonstrated to worsen airway obstruction with reduced VmaxFRC in children with TBM [2], presumed to be due to reduced airway smooth muscle tone. Method Forced Oscillometry Technique (FOT) is a non-invasive technique measuring airway resistance and reactance, which requires minimal co-operation and therefore can be performed in children as young as two years. The patient creates a seal with their lips around a mouthpiece for the duration of ten tidal breaths. Paediatric predicted values are available. [3, 4] Results We present a case where FOT in a child with known TBM showed increased airway resistance (10.11 ± 3.60 cmH2O/(L/S), 163.6% of predicted) and reactance (-2.97 ± 4.20 cmH2O/(L/S), 229.5% of predicted), indicating severe obstruction. Furthermore there was measureable deterioration on administration of beta 2 agonist with airway resistance rising 30.4% (to -2.97 ± 4.20 cmH2O/(L/S), 229.5% of predicted). Conclusion This application of FOT helps to improve management by shaping personalised treatment plans and may reduce iatrogenic harm.

Meredith Robertson <meredith.robertson@gstt.nhs.uk>

Paediatric Respiratory Medicine Department Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London.

Clare Saunders

Royal Brompton Hospital

Introduction: The ECFS Clinical Trials Network (CTN) LCI Core Facility trains operators in the Multiple Breath Washout (MBW) test, providing a pool of certified sites available to sponsors. Certified MBW operators (n>200) across Europe come from a number of professional backgrounds with varying levels of physiology experience. Our training is ideally conducted face-to-face but can also be provided virtually with ongoing support during trials. Centralised over-reading systems are in place to evaluate MBW trial data. We have supported 13 trials to date; success rates are good overall, although some sites require additional support. Objectives: A quality improvement exercise was initiated to 1) understand correlates with varying performance; 2) implement quality improvement initiatives; 3) provide recommendations to sites. Methods: Success rates from 3 recent commercial trials of CFTR modulators were calculated (success rate of >80% acceptable). A survey sent to 48 MBW certified ECFS-CTN sites assessed the operators’ professional background, testing environment and any training needs. Results: From 25 trial participating sites, n=74 operators were medical (32%), physiology/ lung function (8%), nursing/ research co-ordinator (34%), other/ NA (26%). 18 (72%) sites achieved acceptable MBW quality, whereas scores were lower for 7 (28%). Operator background differed significantly in these two groups (Chi2, p<0.01), success being associated with a greater proportion of medical or physiology staff performing MBW. Of the 42 sites which responded, 36% did not follow advice on a suitable testing environment and 75% requested annual refresher training. Conclusions: This initiative has identified that our training may need to be enhanced for operators with less experience in respiratory physiology; a foundation level training module could be beneficial. We will also initiate annual refresher training in order to maintain operators’ skills. A summary of individual site success rates will be provided to each site with personalised training plans implemented. Some sites not partaking in commercial trials still perform MBW, therefore, we are considering a service where sites can submit practice traces for quality control once a year.

Clare Saunders

1. NHLI Imperial College London, London, UK 2. Royal Brompton & Harefield hospitals, part of Guys and St Thomas’ Trust, London, UK 3. European Cystic Fibrosis Society Clinical Trials Network, Kastanieparken 7 7470 Karup, Denmark

Introduction & Objectives: The number of patients presenting to paediatric Emergency Departments (EDs) and Paediatric Intensive Care (PICU) in the UK decreased substantially in 2020 due to the national lockdown strategy in response to the COVID-19 pandemic (1). Prior to the pandemic the most common conditions necessitating referral to the South Thames Retrieval Service (STRS) and admission to PICU were respiratory in particular: asthma, bronchiolitis, pneumonia, and croup (2). Little documentation and research exist about the impact of the pandemic on paediatric respiratory referrals. This study hypothesised that there would be an impact of COVID- 19 on patient’s respiratory patterns and aimed to identify whether seasonality of respiratory diseases still existed during the pandemic, and whether there were differences in respiratory condition referrals prior to and after the first wave of the pandemic in the UK. Methods: The current study was conducted by adopting a quantitative approach using a retrospective chart review. STRS receives approximately 1500 referrals to service from district general hospitals (DGHs) to PICUs , and transfers approximately 950 patients annually of which approximately 40% (450) are usually respiratory referrals (3). The data were collected from anonymised STRS medical records. To be deemed appropriate for inclusion, participants were required to have received a respiratory referral between January 2015 and December 2020 and be aged between 0 to 16 years. The study conducted several analyses to assess the association between COVID-19 and paediatric referral service delivery, including Kolmogorov-Smirnoff and Pearson’s bivariate correlations. The alpha was set at α = 0.05. The PICU and STRS data is collected for national audit purposes (PICANET). Ethics approval was not sought for this study as it was registered as a service delivery audit (12180). Results: A total of 3,002 subjects were included. The study identified a statistically significant difference between the year and pattern of referrals (H(5) = 22.303, p < 0.001). The majority of admissions occurred during autumn (n = 1,044; 34.8%) or winter (n = 970; 32.3%). Peaks in admissions occurred in 2017 (n = 667; 22.2%) and 2018 (n = 695; 23.2%) while in 2020 the admission rate decreased (n=351; 11.7%) (Figure:1). Conclusions: PICU admissions and paediatric retrievals changed throughout the UK during the first COVID-19-related shutdown, which occurred in the early stages of the lockdown itself. COVID-19 pandemic impacted the admission of children to hospitals and South Thames Retrieval Services among paediatric retrievals due to the reduction in hospitalisations compared to previous years.

Sara Alsuwais

College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Introduction and Objectives: Smoking behaviours changed during the COVID-19 pandemic1 we sought to investigate smoking behaviours in parents/carers of CYP post pandemic Methods: We performed a questionnaire study of a total of 89 parents of CYP, known to the smoking cessation clinic from King’s College Hospital. Results: Sixty-one parents were interviewed, nine families had more than one person known to smoke. Forty-one of the families had a child with asthma, seven with cystic fibrosis, one with chronic lung disease, one with bronchiectasis, one with CPAM as an infant and one was known to have aspiration pneumonitis. Twenty-seven (44%) parents smoked less post-pandemic compared with during the pandemic; 32(52%) parents the same; two (3%) are smoking more (Table 1). A significantly greater proportion of parents/carers smoked more during the pandemic compared to post pandemic. More parents gave up smoking post pandemic compared with during the pandemic. A total of 15 (25%) parents have stopped smoking out of whom 6 are vaping now. Of those parents/carers who continue to smoke, they do so on an average of 11 times/day. Thirty-eight (62%) parents have never worked and are full-time carers for their children. Fourteen parents were working during and after the pandemic with no change in their working patterns. Two parents had a mixture of working from home, and in their offices; seven parents have returned to work. Two parents lost their jobs and are not working for the past year. Conclusions: More parents/carers smoked more during the pandemic compared to after the pandemic. As many as 25% of parents gave up smoking post pandemic, which is significantly more than during the pandemic. Only 3% of parents smoked more post pandemic, which is much better than during the pandemic. This highlights the difficulty parents/carers had in giving up smoking during the pandemic. There were no smoking cessation clinics operating during the pandemic. There was more stress on families during the pandemic.1 These factors all contributed to continued tobacco use during the pandemic. Despite the reduction in parent/carer smoking post pandemic, still, over half of parents/carers were smoking the same or more post pandemic, causing significant harm to vulnerable CYP. Seven (11%) were vaping, which in itself is harmful to CYP. We need to encourage parents/carers of CYP to stop smoking with motivation based tools3 . We need to educate them on the dangers of vaping. Over 60% of parents/carers interviewed are full time carers for vulnerable children. There is increased stress in non-working parents due to financial constraints,2 this may contribute to the ability to stop smoking.

Junaid Manzoor

King’s College Hospital, Denmark Hill, London, UK