Lorna E. Latimer1,2,15, Marieke Duiverman3,4,15, Mahmoud I. Abdel-Aziz5,6,15, Gulser Caliskan7,15, Sara M. Mensink-Bout8,9,15, Alberto Mendoza-Valderrey10,15, Aurelien Justet11,15, Junichi Omura12,15, Karthi Srikanthan13,15, Jana De Brandt14 jana.debrandt@uhasselt.be @EarlyCareerERS Early career forum ERS International Congress 2019: highlights from Best Abstract awardees During the 2019 European Respiratory Society life (HRQoL) and dyspnoea [4] while cognitive Cite as: Latimer LE, Duiverman (ERS) International Congress in Madrid (Spain), function improved in COPD after pulmonary M, Abdel-Aziz MI, et al. ERS the author of the Best Abstract (highest average rehabilitation [5]. Striking data on >7000 clinical International Congress 2019: score of abstract reviewers and only those who patients in England and Wales (UK) demonstrated highlights from Best Abstract awardees. Breathe 2019; 15: had not applied for a sponsored award) of every a survival advantage in patients who completed e143–e149. Assembly was awarded with a prize. Best Abstract pulmonary rehabilitation that was independent of awardees were invited to write a short summary of disease severity [6]. their congress experience and view on the evolving On the delivery of pulmonary rehabilitation, field of research in light of their respective assembly. the Clinical Year in Review session highlighted The purpose of this article is to give the readers that patients with COPD and exercise-induced an overview of some of the congress highlights desaturation benefitted from pulmonary and to give a stage to the promising best-abstract rehabilitation without the need for supplemental awardees, as they are the future of the ERS. oxygen [7] while home-based pulmonary rehabilitation may be useful for patients who cannot or do not engage in conventional outpatient pulmonary rehabilitation [8]. Pulmonary Assembly 1: general telerehabilitation produced similar results to pneumology (Lorna E. Latimer) conventional pulmonary rehabilitation but in both groups, short-term improvements were not The functional capacity and physical activity status maintained at 12 months [9]. A post-pulmonary of people with respiratory diseases plus the effects rehabilitation maintenance programme showed of pulmonary rehabilitation dominated the congress encouraging results (although not a randomised agenda. Physical function assessed by 4-m gait trial) with the intervention group maintaining speed showed prognostic value in COPD [1]. In exercise capacity and HRQoL for 4 years asthma, both increasing habitual physical activity [2] and breathlessness scores for 5 years post- and a 3-week intensive pulmonary rehabilitation rehabilitation [10]. However, maintaining physical programme [3] increased asthma control. activity levels in COPD patients may be difficult if Evidence that pulmonary rehabilitation improves they live in a rainy climate [11]. more than just exercise capacity was demonstrated In COPD experimental exercise physiology, across several sessions. Pulmonary rehabilitation transcutaneous electrical nerve stimulation did performed favourably compared to an inhaled long- not improve exercise capacity (by disrupting acting muscarinic antagonist in COPD for measures muscle afferent feedback) but offered further of symptom burden, health-related quality of avenues to explore in this fascinating area [12], @ERSpublications #ERSCongress 2019: highlights from Best Abstract awardees http://bit.ly/2XWlD7Y https://doi.org/10.1183/20734735.0330-2019Breathe | December 2019 | Volume 15 | No 4 e143 ERS International Congress 2019 while eccentric cycling exercise generated lower in the “It takes two to tango: translating scientific lactic acid accumulation and less dyspnoea than findings into clinical applications” symposium concentric cycling [13]. showed how basic science can be translated into clinical application in two major airway diseases: asthma and COPD. For example, Marco Contoli Assembly 2: respiratory discussed how functional imaging techniques can quantify the contribution of small airways intensive care (Marieke as compared to emphysema, and how this could Duiverman) predict lung function decline and disease prognosis in COPD patients [22, 23]. A hot topic oral session It is an interesting time for respiratory intensive was “Beyond type 2 mechanisms in asthma: who are care and home noninvasive ventilation (NIV). A the other players?”, during which speakers discussed new evolving therapy is nasal high-flow therapy potential biomarkers such as neutrophils, microbiota (nHFT), and studies have been presented on its use and sex hormones that could direct diagnostic/ in the intensive care unit [14], in stable COPD during therapeutic decisions in non-type 2 asthma. exercise [15] and in interstitial lung disease (ILD) [16]. Numerous original studies were also presented. In the coming years, more data will be available For example, during “The microbiome: novel data showing the (added) value of nHFT in chronic care, across respiratory diseases” session, Aogáin hopefully showing which patient groups benefit. et al. [24] characterised the airway resistome in Chronic NIV studies mainly focussed on optimisation chronic respiratory diseases using a metagenomics of ventilation techniques, initiation and follow-up approach. They showed that COPD and strategies. Randomised controlled trials (RCTs) bronchiectasis patients had a higher abundance of were presented showing that (telemonitored) home multiple antibiotic resistance genes as compared to initiation of NIV is noninferior to in-hospital initiation severe asthmatics and healthy controls. A study by (in COPD [17], in neuromuscular disease [18] Wedzicha et al. [25] during the “Exacerbations and and in obesity hypoventilation syndromes [19]), clinical impact of airway diseases” session, showed although the additional benefit in terms of costs that treatment with tiotropium/olodaterol reduced seems to depend on the diagnosis, and strategy exacerbation rates compared with tiotropium in a of NIV initiation and follow-up. Furthermore, in post hoc analysis of 9942 COPD patients. Moreover, the poster discussion session “Hot topics in non- during the “Precision meets immunology in invasive ventilation”, it became evident that real- treatment of airway diseases” session, benralizumab life strategies of initial evaluation, selection of was reported by Schwefel et al. [26] to reduce patients and follow-up are often different from the high-affinity immunoglobulin E receptor on those used in RCTs, indicating that there might plasmacytoid dendritic cells in 20 severe asthmatics. be too little insight into barriers and facilitators of In summary, the 2019 Congress covered implementing evidence-based care. There were a broad range of comprehensive topics that presentations about measuring patient–ventilator provide more understanding into the underlying asynchrony (PVA), based on flow and airway pressure, pathophysiological mechanisms and treatment in a sophisticated automatic way [20]. This strategy approaches of airway diseases, asthma and COPD. is attractive as it requires only minimal additional measurements and data can be post-processed to derive an asynchrony index. However, further Assembly 6: epidemiology studies must prove whether this strategy identifies all relevant PVAs adequately and whether these PVAs and environment are associated with important patient outcomes (Gulser Caliskan) [21]. Overall, to improve care, monitoring chronic ventilatory assistance should be practical and lead to Assembly 6 provides an interdisciplinary approach worthwhile benefits. We are currently at the border of to cover various topics spanning from cutting-edge a new area of displacing ventilatory assistance more molecular epidemiology of lung function to clinical, and more to the home while improving NIV quality occupational and environmental epidemiology of by more sophisticated, easy-to-handle, technically respiratory disease, in addition, giving emergent optimised and worthwhile (tele)monitoring. insights on consumption of tobacco products and their control [27]. Khan et al. [28] showed that asthmatic mothers Assembly 5: airway who smoked during pregnancy were at greater risk of adverse pregnancy outcomes such as premature diseases, asthma and COPD birth, low birth weight and small for gestational age. (Mahmoud I. Abdel-Aziz) Feliu and coworkers [29, 30] showed that tobacco control could result in a lower prevalence of smokers In 2019, the ERS Congress included several sessions and higher quit ratios. Therefore, comprehensive in asthma, COPD and airway diseases ranging from tobacco control policies should be considered as they basic to translational and clinical aspects. Speakers are key to reducing the prevalence of smoking and to e144 Breathe | December 2019 | Volume 15 | No 4 ERS International Congress 2019 enhancing tobacco cessation rates in their population. adverse effect of several chemicals on lung function They also highlighted that social inequalities in in children [42]. From a more clinical perspective, heavy smoking necessitates interventions tailored highlights of past years were the translation of the to vulnerable groups. Ravara et al. [31] reported current scientific knowledge into clinical guidelines that prevalence and trends of tobacco use among on which symposia were held at the ERS Congress. inpatients are similar to those observed in the general In the symposium on asthma management, it was population. Therefore, a variety of screening strategies emphasised that children with asthma should not of tobacco use among inpatients will be crucial in be treated with a short-acting β-agonist alone [43]. the future and a systematic, system-level approach Evidence on the long-term management of children in hospitals to quit smoking is recommended. with bronchopulmonary dysplasia is scarce; in the During the “From the health effects of tobacco to symposium, it was suggested that these children the epidemiology of tobacco/electronic nicotine should not be treated with inhaled or systemic delivery system use” session Caliskan et al. [32] corticosteroids and that a multidisciplinary showed that the rates of smoking initiation during approach for the long-term management of young adolescence (11–15 years) increased steeply bronchopulmonary dysplasia is needed [44]. between 1925 and 1980 in females in Australia. For chronic cough in children, it was highlighted After being relatively stable, the rates of smoking that persistent bacterial bronchitis is a common, initiation increased after the 1970s in males. In the but often unrecognised, cause of wet cough in same period, rates in males (16–20 years) decreased children that can be treated with antibiotics [45]. steeply, whereas they increased in females. Initiation Furthermore, complex clinical cases were discussed rates among young adults (21–35 years) decreased with the audience and a panel of experts, including steadily for males, while they started to decrease after the case of a 4-month old girl with pleural effusions the 1950s in females [32]. Increased rates of tobacco who appeared to have a chylothorax [46]. Overall, consumption among young women is worrying not the 2019 ERS International Congress provided a only for health effects in later life but also because broad overview of paediatric respiratory diseases, tobacco consumption during a susceptible time ranging from state-of-the-art research to the early window may impact subsequent generations, possibly origins of lung diseases, and to the presentation and though epigenetic mechanisms [33]. Tobacco control discussion of evidence-based clinical guidelines on activities during the 90’s are likely to have contributed the treatment of these diseases. to the decline in smoking prevalence during recent decades but their effect on smoking initiation should be further investigated. Moreover, a particular focus Assembly 8 – Thoracic should be given to the effect of tobacco control activities during pregnancy. surgery and Transplantation (Alberto Mendoza-Valderrey) One of the highlights of the thoracic surgery and Assembly 7: paediatrics transplantation topics presented during the 2019 (Sara M. Mensink-Bout) ERS International Congress was the symposium on “Lung transplantation (LT) in 2019: where Life-course studies that showed that lower lung are we?”. The importance of ethics in the field of function and asthma in early childhood track into lung transplantation was treated by Are Martin adulthood and might predict the onset of COPD Holm (Oslo, Norway). Dirk Van Raemdonck later in life are a hot topic in the field of paediatric (Leuven, Belgium) provided recommendations for respiratory diseases [34, 35]. It was emphasised that maximising the organ donor pool, emphasising how insight into the modifiable risk factors of lower lung the extracorporeal technology increases the number function and asthma development might provide of viable donor lungs [47], besides improving the a window of opportunity for preventive strategies. outcome after lung transplantation [48, 49]. In Recent research presented at the Congress therefore line with this, Geert Verleden (Leuven, Belgium) focused on potential risk factors including exposure concluded that team expertise is an extremely to environmental factors such as air pollution [36] important factor to improve long-term outcomes and phenolic compounds [37], lifestyle factors following lung transplantation [50]. such as maternal smoking [38] and a selective iron In the poster discussion session “LT: from basic supplementation regime during pregnancy [39], and science to clinical outcomes”, Pandolfi et al. [51] growth factors including a “low birth size–slower demonstrated that activated neutrophils induce body mass index gain” trajectory [40] and visceral the expression of the profibrotic microRNA miR- adiposity [41] and their relation with respiratory 21 in bronchial epithelial cells, suggesting that morbidity. In addition, sophisticated epidemiological this can be a possible therapeutic target in the approaches to study the combined effect of early life context of bronchiolitis obliterans syndrome. Vall exposures and their relation to respiratory morbidity d’Hebron Lung Transplant Unit (Barcelona, Spain) were discussed. For example, one study used an shared their findings on a specific gene signature exposome approach and observed a potential in peripheral blood from long-term survivors with Breathe | December 2019 | Volume 15 | No 4 e145 ERS International Congress 2019 normal allograft function after LT [52, 53]. In worse prognosis and the absence of a corticosteroid addition, they also presented an integrated mRNA treatment effect [57]. and microRNA transcriptomics profiling study that suggests that innate immune system may play a role in long-term survival after lung transplantation. Assembly 13: pulmonary Focusing on clinical studies, Ulvestad et al. [54] vascular diseases showed how high-intensity training improves physical fitness and health outcomes after lung (Junichi Omura) transplantation. Other sessions in this assembly also focused on In basic research, a study presented by Francois presenting general thoracic surgery aspects and the Potus provided further insight into the role of role of ex vivo lung perfusion, highlighting how this metabolic syndrome in the development of technique could improve donor organ quality. pulmonary hypertension (PH) due to left heart Overall, these sessions highlighted the disease (LHD). He showed that precapillary PH due relationship between basic and clinical science in to diastolic dysfunction (induced by supracoronary order to translate findings into clinical meaningful aortic banding in rats) was exacerbated by a results with the goal of improving survival and metabolic syndrome induced by high-fat diet quality of life of lung transplant recipients. and olanzapine. Mechanistically, he showed that pulmonary artery vascular remodelling resulted from an increase in circulating IL-6 due to an overproduction from both the macrophages and Assembly 12: interstitial lung fat tissues. Hence, he showed that blocking IL-6 diseases (Aurélien Justet) signalling improved PH-LHD [58]. A promising study by Takayuki Jujo demonstrated During the 2019 ERS International Congress, several that gut microbiota was associated with the major therapeutic breakthroughs were presented. development of PH in SU5416/hypoxia (Su/ Two studies focussed on the efficacy of antifibrotic Hx) rat model. Furthermore, PH in Su/Hx rats treatments or anti-interleukin (IL)-6 receptor antibody was attenuated by antibiotic treatment. There in progressive fibrosing ILD and in ILD related to is increasing evidence demonstrating the pro- systemic sclerosis (SSc). One study retrospectively pathogenic role of inflammation by microbiota in assessed bronchoalveolar lavage (BAL) lymphocytosis cardiovascular disease [59]. Taken together, these in fibrotic hypersensitivity pneumonitis to predict studies uncover novel mechanisms of the link corticosteroid treatment response. between inflammation and the pathogenesis of PH. The INBUILD trial, a double-blind, randomised, In translational research, there was a pro– placebo-controlled study, assessed the efficacy con debate session on current controversies in and safety of nintedanib in patients with various pulmonary artery denervation for PH. This session non-idiopathic pulmonary fibrosis (IPF) chronic stimulated interest with hot topics, including the fibrosing ILDs with progressive phenotypes. role of the sympathetic nervous system in PH and Nintedanib significantly slowed the progression renal denervation for systemic hypertension. of ILD compared to placebo (difference in forced Finally, the results from ASCO1 study vital capacity (FVC) decline 107.0 mL·year−1, (NCT01086540) were presented by Zamanian p<0.001) [55]. Safety profile in this population was [60]. This clinical trial was designed to assess the similar with that observed in IPF population. efficacy and safety of rituximab in SSc associated In ILD related to SSc, tocilizumab, an anti-IL-6 with PH. Although the first endpoint was negative receptor antibody, showed clinically relevant lung in terms of improvement in 6-min walk distance function preservation but failed to improve the (6MWD) at week 24, he showed the significant modified Ronan skin score endpoint. Conversely, the improvement of 6MWD at week 24 (25.5±8.8 m SENSCIS trial, a double-blind, randomised, placebo- rituximab, 0.4±7.4 m placebo; p=0.03) in a pre- controlled study, revealed that nintedanib significantly specified secondary analysis that included only slowed the FVC decline of SSc patients treated with subjects who were followed until week 48. The prednisone <10 mg·day−1 and/or a stable therapy clinical trial demonstrated that rituximab was a with mycophenolate mofetil or methotrexate [56]. safe and potentially effective treatment for PH-SSc. Hypersensitivity pneumonitis is an ILD caused by sensitisation to an inhaled antigen. Distinguishing fibrotic hypersensitivity pneumonitis Assembly 14: clinical from nonfibrotic hypersensitivity pneumonitis is important, as the extent of histopathological fibrosis techniques, imaging and is associated with survival. One study assessed the endoscopy (Karthi Srikanthan) impact of BAL lymphocytosis and honeycombing presence on corticosteroid treatment effect in 91 As in recent years, the 2019 ERS International patients with fibrotic HP. It revealed that both low Congress included a significant number of BAL lymphocyte count and honeycombing predicted abstracts involving endoscopic techniques. Three e146 Breathe | December 2019 | Volume 15 | No 4 ERS International Congress 2019 of the most interesting abstracts are discussed. at 6 months (−4.44% versus 0.01%, p=0.02) [62]. Firstly, the AIRFLOW-2 trial (randomised, sham- Lastly, metered CryoSpray is a novel bronchoscopic controlled, double-blind trial of targeted lung treatment for chronic bronchitis. Using the denervation (TLD) in COPD) presented its 12-month RejuvenAir system (CSA Medical Inc., Lexington, MA, outcomes. Similar to its 6-month data, there was a USA), liquid nitrogen is aerosolised and applied to significant reduction in the number of patients who the bronchial airways to ablate abnormal epithelium experienced severe COPD exacerbations in the TLD and promote regeneration of a healthy mucosal versus sham arm (12% versus 32%, p=0.039). This lining. The aim of the treatment is to improve quality was also the case with respiratory-related serious of life by targeting mucous overproduction. In a adverse events (15% versus 37%, p=0.042). This multicentre, single-arm study, there was a clinically well-designed trial continues to provide evidence meaningful improvement in St George’s Respiratory that TLD is not only safe but also a signal that Questionnaire total score of −7.9±16.8 (95% CI the denervation technique can be beneficial for −14.2 to −1.6, p=0.008) [63]. patients with COPD. A larger pivotal trial is currently on-going in the USA and Europe [61]. Secondly, the TASMA trial (randomised, controlled trial of Concluding remarks bronchial thermoplasty (BT) in severe asthma) measured airway smooth muscle (ASM) mass in We hope to reach out to and inspire all clinicians endobronchial biopsies before and 6 months after and researchers to submit an abstract for the ERS BT treatment. Whilst BT has previously been shown International Congress 2020 (Vienna, Austria) as to reduce ASM mass, this has never been studied this gives them an opportunity to be elected as using a control group. Using a crossover design, the the 2020 Best Abstract awardee of their assembly. TASMA trial demonstrated significant ASM mass Abstract submission is open until 13 February 2020. reduction after BT compared with standard care Good luck! Affiliations Lorna E. Latimer1,2,15, Marieke Duiverman3,4,15, Mahmoud I. Abdel-Aziz5,6,15, Gulser Caliskan7,15, Sara M. Mensink-Bout8,9,15, Alberto Mendoza-Valderrey10,15, Aurelien Justet11,15, Junichi Omura12,15, Karthi Srikanthan13,15, Jana De Brandt14 1Centre for Exercise and Rehabilitation Science and Institute for Lung Health, NIHR Leicester Biomedical Research Centre – Respiratory, Leicester, UK. 2Dept of Respiratory Sciences, University of Leicester, Leicester, UK. 3Dept of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 4Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 5Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 6Dept of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt. 7Dept of Diagnostics and Public Health, Unit of Epidemiology and Medical Statistics, University of Verona, Verona, Italy. 8The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, The Netherlands. 9Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands. 10Servicio de Neumología, Hospital Universitario Vall d’Hebron, Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. 11Dept of Respiratory Medicine, CHU de Caen, Caen, France. 12Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada. 13Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK. 14REVAL – Rehabilitation Research Center, BIOMED – Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium. 15All authors contributed equally. Conflict of interest L.E. Latimer has nothing to disclose. M. Duiverman reports grants from Philips BV, RESMED Ltd, and Fisher and Paykel Ltd, and grants and speaking fees from Vivisol BV, outside the submitted work. M.I. Abdel-Aziz has nothing to disclose. G. Caliskan has nothing to disclose. S.M. Mensink-Bout has nothing to disclose. A. Mendoza-Valderrey has nothing to disclose. A. Justet has nothing to disclose. J. Omura has nothing to disclose. K. Srikanthan has nothing to disclose. J. De Brandt has nothing to disclose. Support statement J. De Brandt is funded by the Flemish government. The Research of FWO Aspirant J. De Brandt is sponsored by FWO-grant #11B4718N. L.E. Latimer is supported by The National Institute for Health Research Leicester Biomedical Research Centre – Respiratory, UK. Breathe | December 2019 | Volume 15 | No 4 e147 ERS International Congress 2019 References 1. Walsh JA, Nolan CM, Kon SSC, et al. Gait speed and mortality a randomised clinical trial. 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