Chronic obstructive pulmonary disease (COPD) is a complex disease and the management is focused on improving breathlessness, quality of life and healthcare utilisation. Our understanding of COPD phenotypes has improved in recent years and there is an increased drive towards delivering phenotypebased therapies. Lung volume reduction can offer the prospect of life changing benefit in breathlessness and quality of life in a select group of patients with severe emphysema already receiving maximum medical treatment. In spite of the available evidence, very few procedures are being performed relative to the disease burden and prevalence of suitable individuals. Currently the major barriers to patient accessibility are lack in standardised multidisciplinary severe COPD services with easy access to lung volume reduction procedures, as well as poorly informed perceptions of healthcare professionals. There is a recognised need to improve such services in many healthcare systems. We share our experiences with setting up and running a successful regional multidisciplinary severe COPD hyperinflation service.

SUMMARYCyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A noncontrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications. BACKGROUND

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Introduction and objectivesLung volume reduction (LVR) via unilateral VATS or endoscopic placement of endobronchial valves (EBV) in carefully selected individuals with severe emphysema can result in a major improvement in quality of life. Despite being approved by NICE, there remains patchy service provision across the UK.1 In 2010, we established a multidisciplinary COPD Hyperinflation service for our region. There is a scarcity of information on such services and we report on our referral outcomes for 2015.MethodsOur Hyperinflation MDT includes specialist COPD physician, specialist nurse, thoracic radiologist, thoracic surgeon, interventional pulmonologist and transplant physician. We review clinical features, CT and lung function to decide on specialist assessment, progressing to detailed physiological assessment, lung perfusion scanning and MDT discussion in some. We retrospectively reviewed outcomes on 120 patients referred for LVR assessment between 1/1/15–31/12/15.Results111 patients underwent specialist assessment. 20% of patients were discharged, as they did not meet NICE criteria. Nonetheless, many of these patients benefited from clinical phenotyping and management recommendations. 67% of patients were discussed at MDT. 35% of patients were not offered LVR (high risk and lack of hyperinflation targets). 64% of patients were deemed suitable for LVR or transplantation [(EBV or LVRS 37%; LVRS 35%; EBV 15%; EBV bridging to transplantation 7%; transplant 4% (Figure 1)]. One patient received endobronchial coils as part of a clinical study. Patients who are considered suitable for EBV with intact or <10% defect in fissure undergo bronchoscopic balloon catheter assessment for collateral ventilation.ConclusionOur experience with this service model shows that LVR can be incorporated into existing pathways. Our model has evolved to triage patients at various points to ensure high quality discussion of selected patients at the dedicated MDT. As a result, the proportion of patients at the MDT offered LVR procedures is relatively high. MDT expertise allows optimal patient selection with effective utilisation of existing resources. We hope that these data will stimulate others to develop local models of care to enable better access to LVR for COPD patients.Abstract P199 Figure 1Flow of patients through our COPD Hyperinflation service in 2015. MDT: multidisciplinary team; EBV: endobronchial valve; LVRS: Lung volume reducation surgery.* Endobronchial coil was offered as part of a clinical trialReferenceMcNulty W, et al. BMJ Open Respirat Res 2014;1:e000023.