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Papers by Angela Key

Physiological Reports, Apr 1, 2021

This is an open access article under the terms of the Creative Commons Attribution License, which... more This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Clinical Physiology and Functional Imaging, Dec 27, 2022

Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating... more Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating head and neck cancer (HaNC) survivors. Also compare their cardiorespiratory fitness to age and sex-matched norms and establish current physical activity levels. Methods: Fifty HaNC survivors [29 male; mean (SD) age, 62 (8) years], who had completed treatment up to 1 year previously, were recruited. Participants performed a CPET on a cycle ergometer to symptom-limited tolerance. Participants completed a questionnaire to report contributory factors they perceived as influencing test termination. Physical activity levels were determined using a self-reported physical activity questionnaire. Results: Three participants did not complete the CPET because (1) poor fitting mouthpiece and naso-oral mask due to facial disfiguration from surgery; (2) knee pain elicited by cycling; and (3) early CPET termination due to electrocardiogram artefacts. Participants reached a mean peak oxygen uptake that was 34% lower than predicted and the mean (SD) CPET duration of 7:52 (2:29) min:s was significantly lower than the target test duration of 10 min (p < 0.001). Leg muscle aches and/or breathing discomfort were major contributory factors influencing test termination for 78% of participants, compared to 13% for dry mouth/throat and/or drainage in the mouth/throat. No major adverse events occurred. Participants were categorised as 26% active, 8% moderately active, and 66% insufficiently active. Conclusion: These preliminary data suggest the CPET appears safe and feasible for most HaNC survivors when strict exclusion criteria are applied; however, low levels of cardiorespiratory fitness should be considered when calculating an appropriate ramp rate.

Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (... more Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (IPF). This study measured cough rates in IPF patients and investigated the association between cough and measures of health related quality of life and subjective cough assessments. In addition, IPF cough rates were related to measures of physiological disease severity and compared to cough rates in health and other respiratory conditions. Methods: Nineteen IPF patients, mean age 70.8 years ± 8.6, five female (26.3%) were studied. Subjects performed full pulmonary function testing, 24 hour ambulatory cough recordings, completed a cough related quality of life questionnaire (Leicester Cough Questionnaire) and subjectively scored cough severity with a visual analogue scale. Ambulatory cough recordings were manually counted and reported as number of coughs per hour. Results: The 24hr cough rates were high (median 9.4, range 1.5-39.4), with day time rates much higher than night time (median 14.6, range 1.9-56.6 compared to 1.9, range 0-19.2, p = 0.003). Strong correlations were found between objective cough frequency and both the VAS (day r = 0.80, p < 0.001, night r = 0.71, p = 0.001) and LCQ (r =-0.80, p < 0.001), but not with measures of pulmonary function. Cough rates in IPF were higher than healthy subjects (p < 0.001) and asthma patients (p < 0.001) but similar to patients with chronic cough (p = 0.33). Conclusions: This study confirms objectively that cough is a major, very distressing and disabling symptom in IPF patients. The strong correlations between objective cough counts and cough related quality of life measures suggest that in IPF patient's, perception of cough frequency is very accurate.

Clinical Physiology and Functional Imaging

Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating... more Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating head and neck cancer (HaNC) survivors. Also compare their cardiorespiratory fitness to age and sex-matched norms and establish current physical activity levels. Methods: Fifty HaNC survivors [29 male; mean (SD) age, 62 (8) years], who had completed treatment up to 1 year previously, were recruited. Participants performed a CPET on a cycle ergometer to symptom-limited tolerance. Participants completed a questionnaire to report contributory factors they perceived as influencing test termination. Physical activity levels were determined using a self-reported physical activity questionnaire. Results: Three participants did not complete the CPET because (1) poor fitting mouthpiece and naso-oral mask due to facial disfiguration from surgery; (2) knee pain elicited by cycling; and (3) early CPET termination due to electrocardiogram artefacts. Participants reached a mean peak oxygen uptake that was 34% lower than predicted and the mean (SD) CPET duration of 7:52 (2:29) min:s was significantly lower than the target test duration of 10 min (p < 0.001). Leg muscle aches and/or breathing discomfort were major contributory factors influencing test termination for 78% of participants, compared to 13% for dry mouth/throat and/or drainage in the mouth/throat. No major adverse events occurred. Participants were categorised as 26% active, 8% moderately active, and 66% insufficiently active. Conclusion: These preliminary data suggest the CPET appears safe and feasible for most HaNC survivors when strict exclusion criteria are applied; however, low levels of cardiorespiratory fitness should be considered when calculating an appropriate ramp rate.

Thorax, 2014

mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conc... more mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conclusion Patients with COPD were frail compared with the comparator group of current or ex-smokers, independent of age. Frailty status in the patients was associated with a greater severity of the extra-pulmonary involvement including cardiovascular risk based on greater aortic PWV. Increased aortic PWV in frail patients was independent of blood pressure. These findings are consistent with premature cardiovascular ageing in COPD.

Thorax, 2014

mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conc... more mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conclusion Patients with COPD were frail compared with the comparator group of current or ex-smokers, independent of age. Frailty status in the patients was associated with a greater severity of the extra-pulmonary involvement including cardiovascular risk based on greater aortic PWV. Increased aortic PWV in frail patients was independent of blood pressure. These findings are consistent with premature cardiovascular ageing in COPD.

BMJ open respiratory research, 2017

β Blockers are important treatment for ischaemic heart disease and heart failure; however, there ... more β Blockers are important treatment for ischaemic heart disease and heart failure; however, there has long been concern about their use in people with chronic obstructive pulmonary disease (COPD) due to fear of symptomatic worsening of breathlessness. Despite growing evidence of safety and efficacy, they remain underused. We examined the effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in a group of vascular surgical patients, a high proportion of who were expected to have COPD. People undergoing routine abdominal aortic aneurysm (AAA) surveillance were sequentially recruited from vascular surgery clinic. They completed plethysmographically measured lung function and incremental cardiopulmonary exercise testing with dynamic measurement of inspiratory capacity while taking and not taking β blocker. 48 participants completed tests while taking and not taking β blockers with 38 completing all assessments successfully. 15 participants (39%) were foun...

BMJ, May 11, 2016

Peak flow and spirometry tests are often used in the diagnosis and monitoring of respiratory dise... more Peak flow and spirometry tests are often used in the diagnosis and monitoring of respiratory diseases. This article explains how they are done

BJA: British Journal of Anaesthesia, Jun 1, 2015

Background: Perioperative beta-blockade is widely used, especially before vascular surgery; howev... more Background: Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that betablocker therapy would significantly improve CPET-derived physical fitness in this group. Methods: We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (_ V O2) at estimated lactate threshold (θ L) and _ V O2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. Results: Forty-eight patients completed the study. No difference was observed in _ V O2 atθ L and _ V O2 at peak; however, a significant decrease in _ V E = _ V CO2 atθ L and peak, an increase in workload atθ L , O 2 pulse and heart rate both atθ L and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower _ V O2). Conclusions: Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing _ V O2 atθ L and _ V O2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. Clinical trial registration: NCT 02106286.

Cough, Jun 21, 2010

Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (... more Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (IPF). This study measured cough rates in IPF patients and investigated the association between cough and measures of health related quality of life and subjective cough assessments. In addition, IPF cough rates were related to measures of physiological disease severity and compared to cough rates in health and other respiratory conditions. Methods: Nineteen IPF patients, mean age 70.8 years ± 8.6, five female (26.3%) were studied. Subjects performed full pulmonary function testing, 24 hour ambulatory cough recordings, completed a cough related quality of life questionnaire (Leicester Cough Questionnaire) and subjectively scored cough severity with a visual analogue scale. Ambulatory cough recordings were manually counted and reported as number of coughs per hour. Results: The 24hr cough rates were high (median 9.4, range 1.5-39.4), with day time rates much higher than night time (median 14.6, range 1.9-56.6 compared to 1.9, range 0-19.2, p = 0.003). Strong correlations were found between objective cough frequency and both the VAS (day r = 0.80, p < 0.001, night r = 0.71, p = 0.001) and LCQ (r =-0.80, p < 0.001), but not with measures of pulmonary function. Cough rates in IPF were higher than healthy subjects (p < 0.001) and asthma patients (p < 0.001) but similar to patients with chronic cough (p = 0.33). Conclusions: This study confirms objectively that cough is a major, very distressing and disabling symptom in IPF patients. The strong correlations between objective cough counts and cough related quality of life measures suggest that in IPF patient's, perception of cough frequency is very accurate.

Postgraduate Medical Journal, Jun 12, 2018

To measure the number and distribution of crackles in patients with idiopathic pulmonary fibrosis... more To measure the number and distribution of crackles in patients with idiopathic pulmonary fibrosis (IPF) and assess how this relates to measures of disease severity. Fourteen patients with IPF had both the number of crackles per litre of lung volume and lung function measured every 3 months for 1 year. Crackle counts were expressed according to position (upper and lower zones) and whether they occurred during inspiration and expiration. At baseline, crackle count per unit volume was higher at the bases than the apices and higher during inspiration than during expiration. There was a significant relationship between lung function and number of crackles per unit volume. Upper zone crackles during inspiration (crackle count vs forced vital capacity (FVC): r=0.69, p=0.007) and lower zone crackles during expiration (crackle count vs FVC: r=0.55, p=0.04) demonstrated the strongest relationship with lung function. Number and distribution of crackles in IPF relate to physiological measures of disease severity. Inspiratory lower zone crackles were universal and extensive but the presence, hence, development of inspiratory upper zone crackles and expiratory lower zone crackles correlated with measures of poorer lung function. The presence or appearance of these assessed using chest auscultation provides a clinician with simple measure of disease severity, and possibly progression, prompting further physiological assessment and review of treatment.

BMJ Open, Dec 1, 2016

Introduction: Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and ... more Introduction: Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and cardiopulmonary rehabilitation. The effect of peripheral arterial disease (PAD) on oxygen delivery (VO 2) measured by CPET is not known. The aim of this study was to investigate the effect of PAD on VO 2 measurements during CPET. Methods and analysis: We designed a prospective cohort study, which will recruit 30 patients with PAD, who will undergo CPET before and after treatment of iliofemoral occlusive arterial disease. The main outcome measure is the difference in VO 2 at the lactate threshold (LT) between the 2 CPETs. The secondary outcome measure is the relationship between change in VO 2 at the LT and peak exercise pretreatment and post-treatment and haemodynamic measures of PAD improvement (ankle-brachial index differential). For VO 2 changes, only simple paired bivariate comparisons, not multivariate analyses, are planned, due to the small sample size. The correlation between ABI and VO 2 rise will be tested by linear regression. Ethics and dissemination: The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801). Results will be disseminated through scientific journal and scientific conference presentation. Completion of recruitment is expected by the end of 2016, and submission for publication by March 2017.

Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resectio... more Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resection rate at our institution to about 25%. Combined with our high rate of lung cancer diagnosis and targets for rapid investigation and treatment this has dramatically increased the number of detailed lung function tests required. We examined spirometry, lung volumes and lung diffusion to determine whether certain low-risk individuals could be identified who could safely complete only spirometry before surgery We examined detailed lung function in 235 people referred for testing, who were aged 40 years or older and had 10 or more years of cigarette smoking, to determine the number of surgical higher risk individuals identified by DLco and not by FEV1. We classified FEV1 and/or DLco 9/18 (50%) people identified as very high risk, 32/54 (59%) identified as high risk and 45/68 (66%) identified as moderate risk were only identified by DLco and not FEV1. 64/177 (36%) people identified as low risk using FEV1 were not low risk using DLco; including 19/177 (11%) high or very high risk individuals. No other measure, including FVC, FEV1/FVC, RV, IC and IC/TLC, appeared to better identify high risk people than DLco In our population, DLco remains vital to identify people who are higher risk for lung cancer resection and cannot be replaced by simpler lung function measurements.

4.1 Clinical Physiology, Exercise and Functional Imaging, 2016

Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resectio... more Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resection rate at our institution to about 25%. Combined with our high rate of lung cancer diagnosis and targets for rapid investigation and treatment this has dramatically increased the number of detailed lung function tests required. We examined spirometry, lung volumes and lung diffusion to determine whether certain low-risk individuals could be identified who could safely complete only spirometry before surgery We examined detailed lung function in 235 people referred for testing, who were aged 40 years or older and had 10 or more years of cigarette smoking, to determine the number of surgical higher risk individuals identified by DLco and not by FEV1. We classified FEV1 and/or DLco 9/18 (50%) people identified as very high risk, 32/54 (59%) identified as high risk and 45/68 (66%) identified as moderate risk were only identified by DLco and not FEV1. 64/177 (36%) people identified as low risk using FEV1 were not low risk using DLco; including 19/177 (11%) high or very high risk individuals. No other measure, including FVC, FEV1/FVC, RV, IC and IC/TLC, appeared to better identify high risk people than DLco In our population, DLco remains vital to identify people who are higher risk for lung cancer resection and cannot be replaced by simpler lung function measurements.

Physiological Reports, Apr 1, 2021

This is an open access article under the terms of the Creative Commons Attribution License, which... more This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Clinical Physiology and Functional Imaging, Dec 27, 2022

Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating... more Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating head and neck cancer (HaNC) survivors. Also compare their cardiorespiratory fitness to age and sex-matched norms and establish current physical activity levels. Methods: Fifty HaNC survivors [29 male; mean (SD) age, 62 (8) years], who had completed treatment up to 1 year previously, were recruited. Participants performed a CPET on a cycle ergometer to symptom-limited tolerance. Participants completed a questionnaire to report contributory factors they perceived as influencing test termination. Physical activity levels were determined using a self-reported physical activity questionnaire. Results: Three participants did not complete the CPET because (1) poor fitting mouthpiece and naso-oral mask due to facial disfiguration from surgery; (2) knee pain elicited by cycling; and (3) early CPET termination due to electrocardiogram artefacts. Participants reached a mean peak oxygen uptake that was 34% lower than predicted and the mean (SD) CPET duration of 7:52 (2:29) min:s was significantly lower than the target test duration of 10 min (p < 0.001). Leg muscle aches and/or breathing discomfort were major contributory factors influencing test termination for 78% of participants, compared to 13% for dry mouth/throat and/or drainage in the mouth/throat. No major adverse events occurred. Participants were categorised as 26% active, 8% moderately active, and 66% insufficiently active. Conclusion: These preliminary data suggest the CPET appears safe and feasible for most HaNC survivors when strict exclusion criteria are applied; however, low levels of cardiorespiratory fitness should be considered when calculating an appropriate ramp rate.

Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (... more Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (IPF). This study measured cough rates in IPF patients and investigated the association between cough and measures of health related quality of life and subjective cough assessments. In addition, IPF cough rates were related to measures of physiological disease severity and compared to cough rates in health and other respiratory conditions. Methods: Nineteen IPF patients, mean age 70.8 years ± 8.6, five female (26.3%) were studied. Subjects performed full pulmonary function testing, 24 hour ambulatory cough recordings, completed a cough related quality of life questionnaire (Leicester Cough Questionnaire) and subjectively scored cough severity with a visual analogue scale. Ambulatory cough recordings were manually counted and reported as number of coughs per hour. Results: The 24hr cough rates were high (median 9.4, range 1.5-39.4), with day time rates much higher than night time (median 14.6, range 1.9-56.6 compared to 1.9, range 0-19.2, p = 0.003). Strong correlations were found between objective cough frequency and both the VAS (day r = 0.80, p < 0.001, night r = 0.71, p = 0.001) and LCQ (r =-0.80, p < 0.001), but not with measures of pulmonary function. Cough rates in IPF were higher than healthy subjects (p < 0.001) and asthma patients (p < 0.001) but similar to patients with chronic cough (p = 0.33). Conclusions: This study confirms objectively that cough is a major, very distressing and disabling symptom in IPF patients. The strong correlations between objective cough counts and cough related quality of life measures suggest that in IPF patient's, perception of cough frequency is very accurate.

Clinical Physiology and Functional Imaging

Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating... more Purpose: Assess safety and feasibility of the cardiopulmonary exercise test (CPET) for evaluating head and neck cancer (HaNC) survivors. Also compare their cardiorespiratory fitness to age and sex-matched norms and establish current physical activity levels. Methods: Fifty HaNC survivors [29 male; mean (SD) age, 62 (8) years], who had completed treatment up to 1 year previously, were recruited. Participants performed a CPET on a cycle ergometer to symptom-limited tolerance. Participants completed a questionnaire to report contributory factors they perceived as influencing test termination. Physical activity levels were determined using a self-reported physical activity questionnaire. Results: Three participants did not complete the CPET because (1) poor fitting mouthpiece and naso-oral mask due to facial disfiguration from surgery; (2) knee pain elicited by cycling; and (3) early CPET termination due to electrocardiogram artefacts. Participants reached a mean peak oxygen uptake that was 34% lower than predicted and the mean (SD) CPET duration of 7:52 (2:29) min:s was significantly lower than the target test duration of 10 min (p < 0.001). Leg muscle aches and/or breathing discomfort were major contributory factors influencing test termination for 78% of participants, compared to 13% for dry mouth/throat and/or drainage in the mouth/throat. No major adverse events occurred. Participants were categorised as 26% active, 8% moderately active, and 66% insufficiently active. Conclusion: These preliminary data suggest the CPET appears safe and feasible for most HaNC survivors when strict exclusion criteria are applied; however, low levels of cardiorespiratory fitness should be considered when calculating an appropriate ramp rate.

Thorax, 2014

mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conc... more mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conclusion Patients with COPD were frail compared with the comparator group of current or ex-smokers, independent of age. Frailty status in the patients was associated with a greater severity of the extra-pulmonary involvement including cardiovascular risk based on greater aortic PWV. Increased aortic PWV in frail patients was independent of blood pressure. These findings are consistent with premature cardiovascular ageing in COPD.

Thorax, 2014

mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conc... more mean (95% CI), 0.15 (0.14-0.16) than in comparators, 0.05 (0.03-0.05), independent of age, p Conclusion Patients with COPD were frail compared with the comparator group of current or ex-smokers, independent of age. Frailty status in the patients was associated with a greater severity of the extra-pulmonary involvement including cardiovascular risk based on greater aortic PWV. Increased aortic PWV in frail patients was independent of blood pressure. These findings are consistent with premature cardiovascular ageing in COPD.

BMJ open respiratory research, 2017

β Blockers are important treatment for ischaemic heart disease and heart failure; however, there ... more β Blockers are important treatment for ischaemic heart disease and heart failure; however, there has long been concern about their use in people with chronic obstructive pulmonary disease (COPD) due to fear of symptomatic worsening of breathlessness. Despite growing evidence of safety and efficacy, they remain underused. We examined the effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in a group of vascular surgical patients, a high proportion of who were expected to have COPD. People undergoing routine abdominal aortic aneurysm (AAA) surveillance were sequentially recruited from vascular surgery clinic. They completed plethysmographically measured lung function and incremental cardiopulmonary exercise testing with dynamic measurement of inspiratory capacity while taking and not taking β blocker. 48 participants completed tests while taking and not taking β blockers with 38 completing all assessments successfully. 15 participants (39%) were foun...

BMJ, May 11, 2016

Peak flow and spirometry tests are often used in the diagnosis and monitoring of respiratory dise... more Peak flow and spirometry tests are often used in the diagnosis and monitoring of respiratory diseases. This article explains how they are done

BJA: British Journal of Anaesthesia, Jun 1, 2015

Background: Perioperative beta-blockade is widely used, especially before vascular surgery; howev... more Background: Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that betablocker therapy would significantly improve CPET-derived physical fitness in this group. Methods: We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (_ V O2) at estimated lactate threshold (θ L) and _ V O2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. Results: Forty-eight patients completed the study. No difference was observed in _ V O2 atθ L and _ V O2 at peak; however, a significant decrease in _ V E = _ V CO2 atθ L and peak, an increase in workload atθ L , O 2 pulse and heart rate both atθ L and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower _ V O2). Conclusions: Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing _ V O2 atθ L and _ V O2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. Clinical trial registration: NCT 02106286.

Cough, Jun 21, 2010

Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (... more Background: Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (IPF). This study measured cough rates in IPF patients and investigated the association between cough and measures of health related quality of life and subjective cough assessments. In addition, IPF cough rates were related to measures of physiological disease severity and compared to cough rates in health and other respiratory conditions. Methods: Nineteen IPF patients, mean age 70.8 years ± 8.6, five female (26.3%) were studied. Subjects performed full pulmonary function testing, 24 hour ambulatory cough recordings, completed a cough related quality of life questionnaire (Leicester Cough Questionnaire) and subjectively scored cough severity with a visual analogue scale. Ambulatory cough recordings were manually counted and reported as number of coughs per hour. Results: The 24hr cough rates were high (median 9.4, range 1.5-39.4), with day time rates much higher than night time (median 14.6, range 1.9-56.6 compared to 1.9, range 0-19.2, p = 0.003). Strong correlations were found between objective cough frequency and both the VAS (day r = 0.80, p < 0.001, night r = 0.71, p = 0.001) and LCQ (r =-0.80, p < 0.001), but not with measures of pulmonary function. Cough rates in IPF were higher than healthy subjects (p < 0.001) and asthma patients (p < 0.001) but similar to patients with chronic cough (p = 0.33). Conclusions: This study confirms objectively that cough is a major, very distressing and disabling symptom in IPF patients. The strong correlations between objective cough counts and cough related quality of life measures suggest that in IPF patient's, perception of cough frequency is very accurate.

Postgraduate Medical Journal, Jun 12, 2018

To measure the number and distribution of crackles in patients with idiopathic pulmonary fibrosis... more To measure the number and distribution of crackles in patients with idiopathic pulmonary fibrosis (IPF) and assess how this relates to measures of disease severity. Fourteen patients with IPF had both the number of crackles per litre of lung volume and lung function measured every 3 months for 1 year. Crackle counts were expressed according to position (upper and lower zones) and whether they occurred during inspiration and expiration. At baseline, crackle count per unit volume was higher at the bases than the apices and higher during inspiration than during expiration. There was a significant relationship between lung function and number of crackles per unit volume. Upper zone crackles during inspiration (crackle count vs forced vital capacity (FVC): r=0.69, p=0.007) and lower zone crackles during expiration (crackle count vs FVC: r=0.55, p=0.04) demonstrated the strongest relationship with lung function. Number and distribution of crackles in IPF relate to physiological measures of disease severity. Inspiratory lower zone crackles were universal and extensive but the presence, hence, development of inspiratory upper zone crackles and expiratory lower zone crackles correlated with measures of poorer lung function. The presence or appearance of these assessed using chest auscultation provides a clinician with simple measure of disease severity, and possibly progression, prompting further physiological assessment and review of treatment.

BMJ Open, Dec 1, 2016

Introduction: Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and ... more Introduction: Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and cardiopulmonary rehabilitation. The effect of peripheral arterial disease (PAD) on oxygen delivery (VO 2) measured by CPET is not known. The aim of this study was to investigate the effect of PAD on VO 2 measurements during CPET. Methods and analysis: We designed a prospective cohort study, which will recruit 30 patients with PAD, who will undergo CPET before and after treatment of iliofemoral occlusive arterial disease. The main outcome measure is the difference in VO 2 at the lactate threshold (LT) between the 2 CPETs. The secondary outcome measure is the relationship between change in VO 2 at the LT and peak exercise pretreatment and post-treatment and haemodynamic measures of PAD improvement (ankle-brachial index differential). For VO 2 changes, only simple paired bivariate comparisons, not multivariate analyses, are planned, due to the small sample size. The correlation between ABI and VO 2 rise will be tested by linear regression. Ethics and dissemination: The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801). Results will be disseminated through scientific journal and scientific conference presentation. Completion of recruitment is expected by the end of 2016, and submission for publication by March 2017.

Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resectio... more Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resection rate at our institution to about 25%. Combined with our high rate of lung cancer diagnosis and targets for rapid investigation and treatment this has dramatically increased the number of detailed lung function tests required. We examined spirometry, lung volumes and lung diffusion to determine whether certain low-risk individuals could be identified who could safely complete only spirometry before surgery We examined detailed lung function in 235 people referred for testing, who were aged 40 years or older and had 10 or more years of cigarette smoking, to determine the number of surgical higher risk individuals identified by DLco and not by FEV1. We classified FEV1 and/or DLco 9/18 (50%) people identified as very high risk, 32/54 (59%) identified as high risk and 45/68 (66%) identified as moderate risk were only identified by DLco and not FEV1. 64/177 (36%) people identified as low risk using FEV1 were not low risk using DLco; including 19/177 (11%) high or very high risk individuals. No other measure, including FVC, FEV1/FVC, RV, IC and IC/TLC, appeared to better identify high risk people than DLco In our population, DLco remains vital to identify people who are higher risk for lung cancer resection and cannot be replaced by simpler lung function measurements.

4.1 Clinical Physiology, Exercise and Functional Imaging, 2016

Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resectio... more Over the last decade, reorganisation of UK lung cancer services has led to a trebling in resection rate at our institution to about 25%. Combined with our high rate of lung cancer diagnosis and targets for rapid investigation and treatment this has dramatically increased the number of detailed lung function tests required. We examined spirometry, lung volumes and lung diffusion to determine whether certain low-risk individuals could be identified who could safely complete only spirometry before surgery We examined detailed lung function in 235 people referred for testing, who were aged 40 years or older and had 10 or more years of cigarette smoking, to determine the number of surgical higher risk individuals identified by DLco and not by FEV1. We classified FEV1 and/or DLco 9/18 (50%) people identified as very high risk, 32/54 (59%) identified as high risk and 45/68 (66%) identified as moderate risk were only identified by DLco and not FEV1. 64/177 (36%) people identified as low risk using FEV1 were not low risk using DLco; including 19/177 (11%) high or very high risk individuals. No other measure, including FVC, FEV1/FVC, RV, IC and IC/TLC, appeared to better identify high risk people than DLco In our population, DLco remains vital to identify people who are higher risk for lung cancer resection and cannot be replaced by simpler lung function measurements.