Research summary – Sarah Ezzeddine & Neta Fibeesh

Respiratory load perception in overweight and asthmatic children
Victoria MacBean, Lorna Wheatley, Alan C Lunt, Gerrard F. Rafferty
Published in the journal Respiratory Physiology & Neurobiology, February 2017

This study examined differences in children’s awareness of breathing difficulty, specifically the influence of weight and asthma. With obesity on the rise in Western society and asthma being a common long-term medical condition, it is crucial to understand why obese, asthmatic children report more breathlessness than asthmatic children who are not overweight, even when there are no differences in the severity of their asthma. It has previously been suggested that overweight children may have an increased awareness of breathing effort.
This study compared various aspects of breathing across three groups of children: asthmatic children with healthy weight, overweight children with asthma and a control group of healthy weight children. The project involved the children breathing through a device which added resistance to breathing. Children were asked to rate how hard they felt it was to breathe, and the tests also measured the children’s breathing muscle activity to find out how hard the breathing muscles were working as the researchers purposefully increased the children’s effort to breathe.
The anticipated results were that healthy weight asthmatic children and healthy weight children would show similar results, that is that their breathing effort scores would steadily increase as they found it harder to breathe, with the breathing muscles working gradually harder. Meanwhile, the overweight asthmatic children would show a much steeper increase.
From the 27 children who were studied, the results showed that the overweight children gave higher effort scores throughout the tests, but that these increased at the same rate. There were no differences in the way the children’s breathing muscles responded to the tests. The reason for the higher overall effort scores in the overweight asthmatic children was that their muscles are already working harder than the other two groups before the experiment due to the changes that occur in the lung with increased weight. It was then concluded that overweight asthmatic children do not have differences in their awareness of breathing effort, but that their additional body mass means their muscles are already working harder.

This summary was produced by Sarah Ezzeddine, Year 13 student from Harris Academy Peckham and Neta Fibeesh, Year 13 student from JFS School, Harrow, as part of our departmental educational outreach programme.

Research summary – Talia Benjamin

Parasternal intercostal muscle activity during methacholine-induced bronchoconstriction
Victoria MacBean, Claire L. Pringle, Alan C. Lunt, Keith D. Sharp, Ashraf Ali, Anne Greenough, John Moxham and Gerrard F. Rafferty
Published in the journal Experimental Physiology, February 2017

Neural respiratory drive (NRD) is commonly used as a measure of respiratory function, as it measures the overall muscular effort required to breathe in the presence of the changes that occur in lung disease. Both bronchoconstriction (airway narrowing) and hyperinflation (over-inflation of the chest, caused by air trapped in deep parts of the lung) occur in lung disease and are known to have detrimental effects on breathing muscle activity. Electromyography (EMG) is a measure of electrical activity being supplied to a muscle and can be used to measure the NRD leaving the brain towards respiratory muscles (in this study the parasternal intercostals – small muscles at the front of the chest). This study aimed to research the individual contributions of bronchoconstriction and hyperinflation on EMG and the overall effectiveness of the EMG as an accurate marker of lung function.

A group of 32 young adults were tested as subjects for this study, all of which had lung function within normal limits at rest, prior to testing. The subjects inhaled increasing concentrations of the chemical methacholine to stimulate the contraction of airway muscles – imitating a mild asthma attack. Subjects’ EMG, spirometry (to measure airway narrowing) and IC (inspiratory capacity) was measured to test for hyperinflation. Detailed statistical testing was used to assess the relationships between all the measures.

The results show that obstruction of the airway was closely related to the increase in EMG, however inspiratory capacity was not related. The data suggests that the overinflation of the chest had less of an effect on the EMG than the airway diameter (bronchoconstriction). This helps advance the understanding of how EMG can be used to assess lung disease.

This summary was produced by Talia Benjamin, Year 13 student from JFS School, Harrow, as part of our departmental educational outreach programme.

A detailed and reflective account of our recent Panel meeting – Iva Koshova

The first meeting of King’s Muscle Lab Student Advisory Panel began with an introduction on what the future panels will consist of as well as some background on the panel. For example, the laboratory was started by Professor John Moxham, to investigate the function of the respiratory and skeletal muscles and how this changes in people with lung disease. I think that it’s an interesting field of research as it enables a group of people from diverse career backgrounds, from physiology to medicine to biomedical engineering, to come together to conduct research. The research team undertakes clinical physiological research in adults and children with and without lung (or other) diseases. After the initial introduction for the panel, the visiting professionals introduced who they were by outlining their career journey from A levels to what they were currently doing. In this meeting the professionals were Miss Claire Pringle, Dr Peter Cho, Miss Hannah Perry and Dr Alexis Cullen. Then we got into groups of around seven people and started the meeting’s discussion topic which was on tobacco and its effects. Each of the visiting professionals took turns to talk to each group.
The discussions within each group were split in four categories, each of which was tailored to the professionals’ specialisation: physical effects of tobacco with Dr Peter Cho; tobacco and the intersection of mental health with Dr Alexis Cullen; public health and tobacco with Miss Claire Pringle; and imaging the effects of tobacco with Miss Hannah Perry. The discussions were initiated by questions from the professionals which people within the groups answered but the discussions were also integrated with expert input from the professionals. In my group the first discussion was with Miss Hannah Perry where we focused on the chemical properties of tobacco. Whilst some people in my group guessed that there were around 200 chemicals within a cigarette, there are approximately 7,000 including over 60 known cancer-causing chemicals. Some of those carcinogenic chemicals are metals or radioactive compounds. It was interesting to discover more of the chemicals inside cigarette smoke other than nicotine and tar. For example, there is also the fatal carbon monoxide and hydrogen cyanide.
The next discussion was with Dr Peter Cho where we discussed some of the physical effects on the body such as breathlessness due to swelling and narrowing of the lung airways and excess mucus in the lung passages. The most intriguing fact we learned in that discussion, in my opinion was the fact that there is permanent damage to the air sacs of the lungs due to scarring from the constant strain from coughing. In the discussion with Dr Alexis Cullen we were stimulated to think about possible relationships between mental health and smoking. For instance, ways in which we could test whether individuals with mental health are more likely to smoke or whether smoking led to and/or worsened mental health. What I found most fascinating was the fact that research needs to be cautious of third factors that could affect the investigation. For example, a third factor could be the socio-economic background of the individuals causing them to either start smoking or affecting their mental health. The final discussion was with Miss Claire Pringle where we discussed ways in which the government could help solve the public issue of smoking. It was interesting because we were made aware of the difficulties of solving such big problems but also discovered that there are some solutions which worked well within certain areas such as banning smoking from certain public areas but didn’t work as well in other areas. Overall, the discussions were great as we weren’t simply told information we were prompted to think and evaluate information regarding the topic. I think that the panel is a fantastic opportunity because we were able to communicate with professionals on subject matters that interested us and gain knowledge from professionals who specialise in that area. Also, there isn’t really any other way to experience this type of learning experience elsewhere. Moreover, it was beneficial as we could learn about possible routes within medicine related jobs as well as discover more roles within the industry.

Iva Koshova, Year 12, Harris Academy Greenwich

A joint post from three Panel students reflecting on our recent tobacco-themed meeting

Selected students from Harris Experience Advanced attended their first King’s Muscle Lab student panel meeting at King’s College London on Monday as part of their academic cultural enhancement. Established by Professor John Moxham, King’s Muscle Lab is a respiratory and physiology research facility, consisting of academics from all fields of health; such as medicine, physiotherapy and nursing and was created with the purpose of investigating the function of respiratory and skeletal muscles and how this changes in people with lung disease. Their work is largely focused on physiology, which is the study of how the systems of the body work and its relation to different conditions and diseases in which people have problems with their breathing. Being a part of the student panel will provide various opportunities and this first meeting was just the start of them.
The students were joined by visiting professionals working in a variety of departments ranging from Psychosis Studies to Health and Social Care in the United Kingdom Government and they gave presentations outlining their carer trajectories and current research areas and roles. Then it was discussion time. The topic brought to the table was ‘Tobacco and its Effects’, and the students were separated into small groups, each with a professional to discuss.
With Dr Alexis Cullen, an expert in psychosis studies, the groups talked about how smoking links to mental health issues, and observed the fact that there are a lot of other contributing factors to consider when looking at the correlation between smoking and mental health issues, for example; stress, home life and family problems. Ms Claire Pringle currently works in the Department of Health and Social Care, United Kingdom Government and the small group discussion with her looked at the social issues surrounding tobacco. The student panel argued whether tobacco could ever be criminalised, and introduced the comparison of Marijuana, discussing whether the use of it could ever be legalised. The role marketing can play in deterring people from smoking was an avenue which was also explored. Packaging of cigarettes is becoming less appealing in government efforts to try to discourage people from smoking, for example the U.K has begun to adopt cigarette packaging with graphic images on them such as people with rotting teeth, and bold letters which read; ‘Smoking Kills’ also appear on the boxes. The physical effects of smoking were explored with Dr Peter Cho. These consist of addiction to nicotine, many types of cancer, and COPD. Whilst the physical effects of smoking are horrific, the most shocking facts however, came from the discussions with Ms Hannah Perry, of the School of Biomedical Engineering and Imaging Sciences. No one expected to hear that there are around 7,000 chemicals inside cigarettes, and 70 of these are carcinogenic.
After the small group talks, the panel reunited to share the things they had learnt with each other. The afternoon was intellectually engaging and students were able to broaden their knowledge, talking about elements of life they come across each day, but do not necessarily give a second thought. They look forward to the next King’s Muscle Lab meeting and what opportunities for the future, panel membership might mean.

By Eliana Oworu, Uzma Niazi and Gisela Simbana-Tipan
(Year 12, HEA, Harris Academy South Norwood)

Reflections on our recent Panel meeting – Gilad Fibeesh

On 26th of February the Student Panel met to hear from academics and discuss tobacco and its effects. The Panel was comprised of students ranging from Year 11 (like myself and fellow JFS School members) to Year 13 with the vast majority sharing a strong interest in biology and many considering pursuing this, medicine or related sciences as a future career option. The attending schools were JFS School, Harris Academy, Burntwood Academy and Graveney School.
Upon arrival, we were briefed by Dr MacBean regarding the agenda for the day and the future opportunities for the panel members including database updating, summarising published researches and many other forms of work experience. The Panel was subsequently introduced to the visiting academics.
Miss Claire Pringle, working in the Department of Health & Social care told us about the various means used to cut down on the number of peoples starting to consume tobacco. It was particularly interesting to find out that the new green packaging of cigarettes has come as a result of market research used to find that the colour is the least appealing as well as, looking into the difficulties that arise when deterring young people from starting smoking through educating them without patronising them.
With Dr Peter Cho, we focussed on the physiological effects of tobacco on the body especially looking at tar and nicotine and considering how they affect people’s body function such as, by raising blood pressure which increases the risk of blood clots that can cause heart attacks. It was intriguing to discover that the harmful effects of tobacco, in terms of causing cancer, were first noticed when researchers compared the list of doctors that smoked and the list of those that developed cancer and spotted a clear correlation.
The topic of medically imaging the effects of tobacco was looked at with Miss Hannah Perry and the mechanisms behind the 3 main imaging methods (CT, PET and MRI) being the main focus of conversation. I found the fact that usually, a radioactive fluorine isotope, is attached to glucose molecules fascinating as a large amount of the glucose goes to the tumour to provide energy for its rapid cell division. The fact that MRI imaging can be used to locate tumours because the fast growth does not allow the tumour to be properly connected to the lymphatic system, which draws away water, was also interesting.
Finally, with Dr Alexis Cullen we looked at understanding the connection between smoking and psychosis and considered the nature of the relationship: does smoking affect the brain by physically cause the development of this mental illness? Or is there some confounding factor which has a link to smoking and a link to psychosis but no direct causational relationship? This along with thinking about some of the ethical concerns involved with research regarding this connection were all ideas discussed.
Overall, the day was filled to the brim with information, questions and answers with some very interesting academics and it is certain that the entire Panel learnt plenty.

Gilad Fibeesh, Year 11, JFS School, Harrow

Research paper summary – Amazing-Grace Lawal

Effect of endurance exercise on respiratory muscle function in patients with cystic fibrosis

Charles C. Reilly, Katie Ward, Caroline J. Jolley, Lucy Anne Frank, Caroline Elston, John Moxham, Gerrard F. Rafferty

Published in the journal Respiratory Physiology & Neurobiology, January 2012

Cystic Fibrosis (CF) is a genetic disorder in which the genes that control the movement of salt and water in and out of cells are affected, this leads to a build up of mucus mostly in the lungs but also in the liver, pancreas and intestine. The aim of the study was to determine whether high intensity exercise tasks lead to fatigue (where the muscles become briefly less able to generate force) in the abdominal muscles or the diaphragm in patients with CF.

Two groups of people were tested, one group with 10 patients with CF and the other group with 10 healthy subjects. On two different occasions the test subjects went to the lab to carry out tests. On the first occasion the subjects performed an exercise test to characterise the subjects in terms of their exercise performance and to also calculate a work rate, which was used in the second test. The second occasion involved a cycling endurance test, lung function and respiratory muscle strength testing taken on all subjects. Before and after the exercise tests, subjects underwent magnetic stimulation of their diaphragm and abdominal muscles to assess how much force the muscles could generate.

Average exercise time was similar in the healthy subjects and those with cystic fibrosis, as was the intensity of exercise they performed during the test. The measurements taken show that there were not any significant changes in the responses to magnetic stimulation after exercise in both the healthy subjects and those with CF. A decrease the response to magnetic stimulation of greater than 15% is thought to be indicative of fatigue in respiratory muscles, however, none of the subjects saw a decrease larger than 15%, thus leading to the conclusion that fatigue did not occur in any of the subjects.

The fact that that fatigue did not occur in the diaphragm or abdominal muscles after exercise in the patients with CF suggests that feelings of breathlessness and weakness in leg muscles may be more important in limiting exercise performance in those with CF. Further studies are needed in order to exactly understand the factors that hinder exercise performance of those with CF such as muscle function in non-respiratory muscles.

This summary was produced by Amazing-Grace Lawal, Year 13 student from Harris Academy South Norwood, London as part of our departmental educational outreach programme.

Research paper summary – Casril Liebert

Observational study of the effect of obesity on lung volumes

Joerg Steier, Alan Lunt, Nicholas Hart, Michael I Polkey, John Moxham

Published in the journal Thorax, April 2014

With a rise in obesity, a bigger effort must be made to understand all the factors and effects of obesity on the human body. It is already known that obesity is associated with an increase in work of breathing and neural respiratory drive (the muscular effort required to breathe), as well as changes in lung capacities. It can also cause hypercapnic respiratory failure which is when there’s too much carbon dioxide in the blood. However, the effects on the mechanics of breathing are unclear. This study attempts to measure the effect of obesity on lung volume and various pressures in the chest and better understand the physiological differences between different weight people.

9 obese people and 9 normal weight people volunteered to be measured whilst seated and whilst lying on their back. During the study, the subjects breathed into the mouthpiece of a machine called a spirometer which monitors the speed and volume of air movement into and out of the lungs. Pressures in the chest and abdomen were also measured, along with the amount of air remaining in the lungs after a breath out (functional residual capacity, or FRC).

After evaluating results, it was noted that high pressures in the chest are have an important role in the mechanisms of the respiratory system. The chest and abdomen pressures were found to be much higher in the obese group, and the FRC lower. The strength of the breathing muscles were measured and the result showed that the obese group had weaker muscles. There was a direct relationship seen between subjects’ waist circumference and the chest and abdominal pressures, as well as with the drop in FRC.

One of the main conclusions is that gastric and oesophageal pressures correlated with waist size, since the obese group had significantly higher pressures. One can deduce from this result that these high pressures are inhibiting efficient function of the lungs, and contributing to the reduced volume of air in the lungs. To bring this research into practical everyday healthcare, more could be done to attempt to reduce abdominal pressures in obese patients. By doing so with appropriate treatment in the future, obese people may be able to reach normal lung function, thereby reducing the number of patients suffering from breathlessness and sleeping disorders from respiratory problems.

This summary was produced by Casril Liebert, Year 13 student from JFS School, Harrow, as part of our departmental educational outreach programme.

Research paper summary – Djenné Oseitwum-Parris

Measurement of neural respiratory drive via parasternal intercostal electromyography in healthy adult subjects

Victoria MacBean, Cara Hughes, Gavin Nicol, Charles C. Reilly, Gerrard F. Rafferty

Published in the journal Physiological Measurement, October 2016

Parasternal intercostal electromyography (EMGpara) is a method used to measure breathing function by monitoring signals sent from the brain, to the parasternal intercostal muscles (muscles between the ribs). These muscles, together with the diaphragm (a thin muscle under the lungs) and some others, move together to control your breathing. EMGpara can be used to measure a person’s neural respiratory drive (NRD), which is an indication of the strength of the respiratory (breathing) muscles under a certain amount of strain (how hard the muscles may have to work when they are coping with different diseases or environments). This method is an alternative to other more traditional practices that, for example, may involve the use of needles. Therefore, EMGpara is less invasive and ideal for monitoring the breathing muscles in many groups of people.

In the case of this study EMGpara was measured in healthy adults in order to discover what factors determine normal EMGpara readings. The participants were over the age of 18, and were of different body types and sexes.

In preparation for the EMGpara tests, each participant’s body size, shape and composition was measured – this included taking note of their height, weight, hip and waist size, body fat percentage and body mass index – as well as tests to confirm that each person had normally functioning lungs.

Electrode stickers were placed on the chest to measure the EMGpara signals as the subjects breathed normally and effortfully. The tests were repeated at a later date to make sure the results could be reproduced, thereby checking that the EMGpara technique is consistent.

The study suggests that sex is the most important factor in determining EMGpara; a higher value for EMGpara was observed in the women who took part. This may be because in general, woman have smaller lungs and narrower airways compared to men and their respiratory muscles are usually not as strong.

Age did not seem to have a significant effect on the readings; however this could have been because the average age of those involved was only 31, and those who were older were quite athletic, meaning their respiratory health was very good.

The results of this study can be used as a reference for what a normal EMGpara reading is, and therefore they can be used when assessing patients in the future. The study included many people from different backgrounds, so it is quite representative of the population. The study was also important in working out which methods and techniques are best for measuring EMGpara, as well as for highlighting possible areas of further research for future studies.

This summary was produced by Djenné Oseitwum-Parris, Year 12 student from Burntwood School, Wandsworth, as part of our departmental educational outreach programme.

A third Student Panel member writes about her practical experiences

On 5th July, we explored how researchers use an EMG to measure the effort the intercostal muscles exert during breathing. We did four tests on an employee, Galia. The first test was when DSC_2259she was breathing normally with no resistance and her results were recorded on an EMG trace which we extrapolated from and recorded on a table. We carried out the other three tests using different tube lengths (representing different stages of resistance) which were attached to a mask. While collecting the results we found that one of the results did not fit the pattern. To resolve this issue we should have repeated the experiment at  least three times. We tried out the equipment on ourselves and found how different factors affected the EMG trace e.g. your posture and slight movements can cause your intercostal muscles to work harder therefore the peaks on tDSC_2258he EMG trace are taller. We learnt that testing on children is hard work as they cannot stay still for a long period of time so you need to use certain tactics like putting on Peppa Pig to keep them entertained. We thoroughly enjoyed our experience and learnt valuable knowledge.
Trinecia Compton, Year 12, Burntwood Academy

Another Student Panel member explains her practical session

On 5th July was our second Student Panel meeting where we were fortunate enough to receive hands-on practical experience in the labs of the Chest Unit at King’s College Hospital! Our main point of interest today was to investigate measurements of inspiratory and expiratory muscle strength. The session started with all the members reintroducing ourselves to one another and speaking about what we study and what we would like to do in the future. It was great to catch up again and meet new members who I didn’t see at our last meeting! I made a load of new friends who gave me valuable tips regarding university and a career in medicine and science. These activities made us all feel very welcome again and very excited for the afternoon!

We were split into three groups depending on what we’d prefer to investigate and I chose to do respiratory muscle testing. My team’s practical was led by Brittany BestIMG_20170718_161321 who is a current MSc student. Britt was extremely supportive and reassuring which made us find the practical easy and exciting to carry out. She started by teaching us the names and functions of the equipment which we were going to use; these included nose bungs, mouth pieces and a 3-chamber metal valve which we all used at some point of our practical. We also got to pop in to the other group’s rooms and see the cool stuff they were using such as an ECG! In my team, we performed measurements of inspiratory and expiratory muscle strength using the PImax, PEmax and SNIP technique. The PImax was much harder to carry out because we were not used to the equipment but also because it was so unusual to us! This made us think about how difficult a healthcare professional may find it to get accurate data from a patient’s results as patients can often be giggly or even find the unusual technique very awkward and hence will alter their breathing pattern, either purposefully or subconsciously. To obtain results, patients must suck air into their lungs through a mouth-piece. This may sound simple at first, however it quickly challenged our lung muscle ability when my partner was told to close one of the valves. It felt as though my lungs were about to burst because I couldn’t breathe in any air after a certain point due to the valve, but was generating a lot of pressure in my lungs! The SNIP test was much easier to do as it just involved sticking a nose-bung up your nose and breathing regularly with a little twist: give a powerful sniff after every third breath out. Although it isn’t the most fashionable way to gather results, it sure was easier!

IMG_20170718_161324Once we all had a chance to take on the roles of both a patient and the scientist, we each analysed our data to see if our values fell into the predicted range values. After a couple of attempts with Brittany reassuring us that it is tough when you’re new to it, we finally got the hang of it! Our values started looking normal as we got more used to the test.

Once we finished our practical, we then all discussed how these tests might be adapted to different patient populations including younger children or those on intensive care. We discussed about how someone on intensive care may not be able to breathe as they usually would and hence more invasive measures would be taken into consideration such as a technique which runs a tube through your nose and down the back of your throat which allows successful results to be collected. We also thought of the difficulties an individual may face due to weakened IMG_20170718_161256muscle strength such as those who suffer from motor neurone disease. The team spoke about how hard it must be for somebody’s biceps to always feel very painful and heavy as if a heavy bag was attached on to them! This made us reflect and contemplate about how difficult their home life could be, especially if they lived alone as simple everyday activities such as walking up the stairs could be a challenge to them.

The day was just as expected: very fun and factual! I always enjoy our student panel meetings as each meeting is different from the rest and always involves activities which I have never done before or even knew existed!

Huge thank you again to Dr Vicky MacBean and everybody else who works hard to make all our meetings amazing!

Sarah Ezzeddine, Year 12, Harris Academy Peckham