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SELECTED ABSTRACTS
Year : 2015  |  Volume : 32  |  Issue : 8  |  Page : 43-81  

NAPCON Awards


Date of Web Publication26-Oct-2015

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How to cite this article:
. NAPCON Awards. Lung India 2015;32, Suppl S2:43-81

How to cite this URL:
. NAPCON Awards. Lung India [serial online] 2015 [cited 2017 Sep 20];32, Suppl S2:43-81. Available from: http://www.lungindia.com/text.asp?2015/32/8/43/168256

NAPCON AWARD-30




   Asthma Top


Efficacy of yoga in asthma

Surya Kant, Shruti Agnihotri, R. K. Mishra, S. K. Mishra


Department of Respiratory Medicine, King George's Medical University, and Department of Biochemistry, LU, Human Consciousness and Yogic Science, LU, Lucknow, Uttar Pradesh, India. E-mail: skantpulmed@gmail.com

Aim and Objective: To evaluate the role of yoga on symptom scores, pulmonary functions and biochemical changes in the patients of asthma.

Materials and Methods: A total of 276 subjects of mild-to-moderate persistent asthma (FEV1 > 60%) aged between 12 to 60 years were recruited from the Department of Pulmonary Medicine, King George's Medical University, Uttar Pradesh, Lucknow, India. They were randomly divided into two groups, 'the yoga group' (with standard medical treatment along with yogic intervention) and 'the control group' that received standard medical treatment (without yogic intervention). At completion of 6 months of the study period 35 subjects were dropped out, so out of 276 subjects, only 241 subjects completed the study (121 subjects from yoga group and 120 subjects from control group).

Results: Day time symptom, night time symptom and total symptom score decreased significantly in both groups but the improvement was achieved earlier by 'the yoga group' in comparison to 'the control group'. No significant changes were found in spirometrical variables in the control group during the course of the study. 'Between group differences' were found to be highly significant with better improvements in FVC, FEV1, and FEV1/FVC and PEFR. In yoga group, the significant improvements were found in the proportion of hemoglobin and superoxide dismutase activity in comparison to control group and significant decrease was found in total leukocytes count and differential leukocytes count in comparison to control group.

Conclusion: The yoga group got significantly better improvement in symptom scores, pulmonary functions and biochemical variables. Result shows that yoga can be practiced as an adjuvant therapy along with standard inhalation therapy for better management of asthma.

Bronchoprovocative tests in diagnosing asthma

Safia Ahmed, D. Bhattacharyya


Military Hospital (Ctc), Pune, Maharashtra, India. E-mail: safia.ahmed.khan@gmail.com

Aim and Objective: (1) To diagnose airway hyperresponsiveness (AHR) a hallmark of asthma in patients having symptoms of cough, wheeze, breathlessness, chest tightness, reduced exercise tolerance and a normal spirometry with no significant bronchodilator reversibility by using two standard methods of indirect airway challenge, (2) to compare the efficacy of two standard indirect airway challenge methods, exercise testing versus inhaled adenosine monophosphate in diagnosing AHR.

Materials and Methods: 30 patients referred from peripheral hospitals between Jan 2014 and Aug 2015 with symptoms suggestive of asthma of at least 02 months duration with normal pre and post bronchodilator spirometry were included in the study after ruling out all other causes for the symptoms. Local ethical committee clearance and written informed consent from patients were taken. All patients were subjected to both exercise testing and bronchial challenge using inhaled adenosine monophosphate (AMP) using dosimeter on separate days after stopping all medications for 48 hours. Tests were performed and results interpreted using ATS/ERS criteria.

Results: All 30 patients completed both the tests. AHR positivity was taken as 10% fall in FEV1 post exercise as per ERS criteria and a positive AMP (PC 20) provocative concentration of AMP producing a 20% fall in FEV1 of 200 mg/ml. Positivity to either of the test was taken as positive. 10 were positive for both, 12 were negative for both. Six who were negative on exercise testing were positive on AMP challenge and 02 positive for exercise challenge were negative on AMP. We found 60% prevalence of AHR percentage positivity of exercise testing alone was 66.6% and AMP challenge alone was 88.8%.

Conclusion: Both exercise challenge testing and inhalation of AMP are useful adjuncts in diagnosing Airway hyper responsiveness AMP challenge diagnosed more cases than exercise testing alone. If both tests are done then larger number of cases can be diagnosed.

Study of induced sputum cytology in chronic obstructive pulmonary disease and asthma

Bipasha Ghosh, Subhra Mitra, Anjan Kr. Das, Angira Dasgupta


Calcutta National Medical College, and B R Singh Hospital, Kolkata, West Bengal, India. E-mail: drbipashag@gmail.com

Aim and Objective: To characterize airway inflammation in patients with COPD and asthma by quantitative analysis of induced sputum.

Materials and Methods: The study was an Institution based cross sectional study on OPD patients attending Pulmonary Medicine Department. 26 COPD patients and 39 asthma patients were included in the study. At first spirometry was done with bronchodilator. The patients were nebulized with 3% NS using ultrasonic nebulizer for 7 minutes. Spirometry was repeated to check any change of FEV1. Then the patients were again nebulised with 3% NS for 7 minutes. Sputum samples were collected after this procedure and sent to laboratory immediately.

Results: Out of 65 patients, 62 patients (COPD 26, asthma 36) were able to produce sputum after induction. It was found that induced sputum total cell counts were higher in the COPD group compared to the asthmatics, but the difference did not reach statistical significance (p=0.3902). Sputum differential counts showed a predominance of neutrophils (p=0.0001) in COPD patients while eosinophils (p=0.0463), lymphocytes (p=0.1465) and macrophages (p=0.0014) were more frequently seen in asthma groups. It was also observed that some COPD patients (5 cases) showed eosinophil count above 5% and some asthmatics (2 cases) showed neutrophil count above 60%.

Conclusion: Thus in most of the COPD patients neutrophils predominate the inflammation and most of the asthmatics eosinophils predominate the inflammation. But some COPD patients show eosinophilic inflammation and some asthmatics show neutrophilic inflammation. Sputum cytology is important to identify the type of inflammation and treat accordingly. This method is simple, safe and noninvasive.

Skin prick test of food allergens in asthma/rhinitis patients

Manu Gupta, N. C. Kajal, Balbir Malhotra, Nidhi Mahajan, Manish Sahu, Abhishek Tiwari


Department of Chest/TB, GMC, Amritsar, Punjab, India. E-mail: drmanugupta20@gmail.com

Aim and Objective: Food allergens are very common offending agents responsible for bronchial asthma and allergic rhinitis. Food allergy is an abnormal or exaggerated immunologic response to specific food proteins. Food allergies affect 6-8% of children before the age of 5 years and 3-9% of adults in industrialized countries which may manifest as atopic dermatitis, acute urticaria, angioedema, rhinitis, asthma, laryngeal oedema and sometimes life threatening anaphylaxis. This led us to undertake this study regarding skin sensitivity to various food allergens in patients of bronchial asthma and/or allergic rhinitis. Skin prick test (SPT) is the most effective diagnostic test to detect these IgE mediated type-1 allergic reactions.

Materials and Methods: This study was conducted in Department of Chest and TB at Government Medical College, Amritsar. A total of 3300 SPT with 66 food allergens were performed in 50 patients of bronchial asthma and/or allergic rhinitis in the age group of 7 years and above.

Results: Out of 50 patients who underwent SPT, 42% (21) were females and 58% (29) were males. Majority, that is 76% (38) were below the age of 30 years and 24% (12) were above 30. 49 (98%) were sensitive for one or more allergens. Most common offending food allergen was rice (48%) followed by Bengal gram (44%), milk (40%), banana ripe (34%), groundnut (30%), citrus (lemon) and orange (26%) each, peas (24%) and dal masoor, dal moong and dal moth (16%) each. Among non-vegetarian foods, Egg white (42%) was most common food allergen followed by fish (36%) and chicken (30%).

Conclusion: Common food allergens in patients of bronchial asthma and/or allergic rhinitis were identified, amongst which rice was the most common allergen in vegetarian food and egg white was most common allergen in non-vegetarian food. Data may prove useful in allergen avoidance and immunotherapy in these patients

Treatment response in asthmatics with positive bronchial provocation test

K. P. Nimisha, K. Muhammed Shafeeq, C. P. Rauf


Chest Hospital, Calicut, Kerala, India. E-mail: kpnimisha@gmail.com

Aim and Objective: To assess the response to treatment in asthma patients with chronic cough, who had a positive bronchial provocation test (BPT); and to assess the association between methacholine sensitivity and treatment response.

Materials and Methods: A retrospective study based on the medical records and data of patients with chronic cough, who were positive on methacholine bronchial provocation test; and who had received 4 weeks of specific asthma therapy, were reviewed. Treatment response was assessed based on initial and follow up CQLQ scores. The patients in whom the CQLQ score has returned to the baseline score during follow up were considered to be responsive for treatment.

Results: A total of 50 patients who met the inclusion criteria were enrolled in the study. The concentration of methacholine for a positive BPT (pc 20) was 4 mg/ml in 22 (44%) patients, and it was 0.0625 mg/ml and 0.25 mg in 1 (2%) patient each. 11 (22%) had pc 20 of 1 mg/ml and 15 (30%) were positive at high concentration of methacholine (16 mg/ml). Among the 50 BPT positive patients 41 (82%) clinically responded well to treatment for asthma, but 9 (18%) patients had no relief of their symptoms. Our study showed a significant association between initial CQLQ score and clinical response to treatment. However, no significant association was found between duration of cough and response to treatment.

Conclusion: Methacholine challenge test is a useful test for diagnosing cough variant asthma. There is no definite association between pc 20 of methacholine and response to asthma therapy in patients with cough variant asthma.

Reasons for non-adherence in bronchial asthma

Caroline Simon, Ram B. Deoskar, Medha D. Bargaje, Anita Anokar


B.V.D.U.M.C., Pune, Maharashtra, India. E-mail: dr.carolinesimon@gmail.com

Aim and Objective: To evaluate the adherence to treatment and reasons for non-adherence in patients with bronchial asthma coming to a tertiary care hospital in Pune. To evaluate the adherence to treatment in patients with bronchial asthma and to determine the reasons for non-adherence.

Materials and Methods: This was a prospective study of 100 adult bronchial asthma cases coming to a tertiary care hospital in Pune. The duration for inclusion in the study was 18 months and patients were followed up for 6 months. Approval of Ethical Committee was obtained prior to commencement of study. Help of a statistician was taken for analysis of the data.

Results: There were 52 males and 48 females in the study. 73% of patients were non-adherent and 27% were adherent. Non-adherence was more common in males (84.61%) as compared to females (60.41%). The most common reason for non-adherence was that they felt better on treatment and underestimated the severity of asthma (50.68%). Other reasons for non-adherence were forgetfulness/complacency toward treatment, distance of the hospital being too far from the residence and drugs being expensive. A few patients also had awkward regimes, side effects and fear of side effects, steroid phobia and cultural and religious issues. 88.09% of patients who were diagnosed and put on treatment outside were not instructed properly on the use of inhalers and hence 81.25% of them had wrong techniques.

Conclusion: Adherence remains a major problem in the management of asthma. To improve adherence, there is a need for education of both patients and general practitioners.

Knowledge and management of asthma on basis of GINA

Siddharth Raj Yadav, Mahip Saluja, Kamran Choudhry, Nitin Kumar, Pankaj Singh


Subharti Medical College, Meerut, Uttar Pradesh, India. E-mail: drsid28@gmail.com

Aim and Objective: Knowledge and management of asthma on basis of GINA guidelines among residents and EMO in a tertiary care hospital.

Materials and Methods: The study was carried out in tertiary hospital and a total of 30 physicians were enrolled from different department. 28 multiple choice questions based on GINA guidelines were put to test. The results were grouped according to qualification of physicians as well as according to the speciality.

Results: It was found that maximum knowledge was among the residents of pulmonary medicine followed by medicine, paediatrics, ENT, community medicine and least by EMO's.

Conclusion: Regular CME based programs on GINA guidelines should be conducted for physicians by medical education committee for better understanding of asthma as to provide a quality care to patients.

Wheeze in school children of various economic status

A. R. Anjana, C. Davis Paul, Thomas George


Government Medical College, Thrissur, Kerala, India. E-mail: anjanamithran@gmail.com

Aim and Objective: There are studies showing an increase in prevalence of asthma in high socioeconomic group and an increase in severe asthma and asthma related mortality among low socioeconomic group. This study is to know the exact situation in our locality as there is paucity of data in this aspect. To find out prevalence of wheezing and its severity in school children belong to high and low socioeconomic classes.

Materials and Methods: This cross sectional observational study was conducted among school children of age 12-15 years in a private and Govt. HS in our locality using a semi structured validated ISAAC questionnaire.

Results: Of the 596 filled up questionnaires received 64 were excluded and the rest 532 were analyzed. Children belong to each socioeconomic group were as follows. Upper class 1.1% (n=6), middle class upper 25.5% (n=136), middle class lower 26.5% (n=141), lower class upper 46.4% (n=247), lower class 0.3% (n=2). Children with history of wheezing in the past were 61 (11.4%). Prevalence of wheezing in each socioeconomic class was upper 16.6% (n=1), middle upper 19.1% (n=26), middle lower 6.3% (n=9), lower upper 10.1% (n=25), lower 0%. There was a significant difference in prevalence of wheezing between high and low socioeconomic class (chi square 14.29, p value <0.01). But no significant difference in wheezing severity (assessed by frequency, nocturnal symptoms, difficulty in speech and school absence) between groups.

Conclusion: Prevalence of wheezing was more in children of high socioeconomic class but there was no difference in the severity between the two groups.

Correlation of pollen counts and allergy patients

Nishtha Singh, Udaiveer Singh, Dimple Singh, D. K. Mangal, Virendra Singh


Asthma Bhawan, Jaipur, Rajasthan, India. E-mail: drnishthasingh@gmail.com

Aim and Objective: Environmental pollens are known to cause exacerbation of symptoms of patients with allergic rhinitis (AR) and asthma. During pollen months, number of patients visiting hospital has been shown to increase in some studies. However, in India such studies are lacking. Therefore we aimed to study pollen counts and correlation with number of new patients attending Asthma Bhawan for two years.

Materials and Methods: Aerobiological sampling was done using Burkard 24 hrs spore trap system. The site selected for the entrapment of the air spore was the building of Asthma Bhawan situated at Vidhyadhar Nagar, Jaipur. New patients coming with problems of respiratory allergy such as allergic rhinitis or asthma were recruited in the study. Skin prick tests were carried out after obtaining consent in these patients. Monthly pollen counts of trees, weeds and grass were correlated with the number of new patients. Pollen calendar was prepared for two years.

Results: During 2011 and 2012 number of pollens were 13738 and 15305 respectively. In the analysis 37 types of species were identified. Pollen counts showed two seasonal peaks during March-April and from August to October. January and June showed the lowest pollen counts in two years. Average monthly count of Grass pollens showed significant correlation with number of new patients (r= 0.59). Monthly pollen count of trees and weeds did not correlate with the number of new patients. The correlation of the pollen count of individual pollen with the skin prick test positivity to that pollen showed significant correlation with Chenopodium album only.

Conclusion: It can be concluded that there were two peaks of pollen count in a year. Average monthly pollen counts of grass were significantly correlated with the number of new patients.


   Bronchopulmonary Infections Top


Non resolving pneumonia-puzzle of pulmonology!!!

R. Saravanavasan, D. Ranganathan, O. R. Krishnarajasekar, A. Mahilmaran, V. Sundar, N. Murugan


Institute of Thoracic Medicine/MMC, Chennai, Tamil Nadu, India. E-mail: saravana5206@gmail.com

Aim and Objective: To study the clinico-radiological profile and microbio-pathological etiology of non-resolving pneumonia (NRP). To compare bronchial wash gene-xpert vs bronchial wash AFB in diagnosing tuberculosis, in NRP.

Materials and Methods: Our study, done over a period of 8 months, 55 consecutive patients with non-resolving pneumonia were evaluated. Detailed history, clinical examination, routine investigations, CT chest and other relevant investigations were done. Bronchoscopy (FOB) and bronchial wash were done in all patients and sent for gene-xpert and other microbio-pathological investigations. Post bronchoscopy sputum was sent for AFB smear/cytology. Endobronchial biopsy, TBLB, CT guided biopsy as necessary were done.

Results: Out of 55 patients, 80% (n=44) were males, 20% (n=11) were females. 78.2% (n=43) were >40 years. The most common presenting symptom was cough with expectoration 54.5% (n=30), followed by dyspnea 16.4% (n=9). When cause for NRP is diagnosed as malignancy, chest pain followed by hemoptysis (P-value 0.000) were the cardinal symptoms. The average duration of symptom is 7.5 weeks and in cases diagnosed with tuberculosis it is 6.5 weeks (P-value 0.000). Comorbidities were present in 75% (n=41), most common being diabetes 44% (n=18), followed by COPD 24% (n=10). When a patient having COPD presents with NRP, it is more likely to be diagnosed as malignancy (P-value 0.000), followed by tuberculosis (P-value 0.024). Left upper lobe is most commonly involved, followed by right upper lobe and diffuse involvement equally. Bronchoscopy was diagnostic in 39/55 cases, the yield being 71%. Bronchial wash gene-xpert has an additional yield of 48% in diagnosing tuberculosis against bronchial wash AFB. Bronchial wash AFB (P-value 0.000), post FOB AFB (P-value 0.014) provides no additional yield when compared with bronchial wash gene-xpert. Causes diagnosed were tuberculosis 41.8% (n=23), other bacterial pneumonia 14.5% (n=8), malignancy 12.7% (n=7), others 23.7% (n=13) and undiagnosed 7.3% (n=4).

Conclusion: Non-resolving pneumonia is caused by a wide spectrum of diseases, ranging from tuberculosis to malignancy. It is more common in persons above 40 years, particularly males with comorbidities. NRP in COPD patients, is an ominous sign, more chances of it being malignancy. Bronchoscopy was found to be safe and useful in NRP. Our study suggests bronchial wash gene-xpert can be included in the NRP investigation panel. Early bronchoscopy (within 2-4 weeks) is needed in NRP when tuberculosis is suspected, to prevent community transmission.

The clinical profile of H1N1 patients

Harry Jacob George, K. A. Ameer, Kesavan Nair, P. Arjun, Vinod Kumar Kesavan, Abin Varghese


Kerala Institute of Medical Sciences, Trivandrum, Kerala, India. E-mail: harryjacobg@yahoo.co.in


Aim and Objective: To assess the clinical profile of patients who were found positive for H1N1 influenza at a tertiary care centre in South India.

Materials and Methods: This was a retrospective observational study done in a group of patients with H1N1 influenza infection confirmed by throat swab RT-PCR in KIMS hospital, Trivandrum, Kerala. The duration of the study was 7 months from January 2015 to July 2015. The details of patients who were found to be positive for H1N1 influenza infection during the stipulated period of study were collected from the hospital records. Basic epidemiological data, initial clinical presentation, investigation findings, details of hospital stay, complications, need for mechanical ventilation and outcome were documented for each case. The data were analysed using appropriate statiscal tools.

Results: During the period of study there were 205 suspected cases of influenza of which 68 turned out to be positive for H1N1. It was found to be more commen in age group 15-60 years, i.e. 51 patients (75%). Majority were females - 44 (64.7%), 49 (72%) patients had risk factors like asthma 15 (22%), DM 14 (20.5%), pregnancy 8 (11%) and smoking 4 (5.8%). The common presenting symptoms were fever 63 (92.6%), cough 60 (88.2%), breathlessness 41 (60%), myalgia 23 (33.8%), rhinitis 20 (29.4%), sore throat 7 (10%) and loose stools 5 (7.3%). 43 patients had radiological evidence of infiltrates with bilateral involvement in 38 patients (88%). Increased risk of developing pneumonia was seen in patients with delay in starting treatment (48.8%), asthma (18.6%), DM (20.9%), smoking (9.3%) and immunosuppression (6.9%). Among the 68 patients 34 (50%) were admitted in ICU. 32 (47%) patients required mechanical ventilation of which 18 (26.4%) had non invasive and 14 (20.5%) had invasive ventilation. Among 43 patients with pneumonia 7 (16.2%) had ARDS, 6 (13.9%) had leukopenia, 3 (6.9%) altered LFT thrombocytopenia 2 7 (10.2%) patients died of which sepsis 4 (5.8%) and ARDS 3 (4.4%) patients.

Conclusion: 68 patients were confirmed to have H1N1 influenza. 7 patients died, 4 had sepsis and 3 had ARDS. 43 patients had pulmonary infiltrates. 32 needed ventilatory support, 18 non invasive and 14 invasive. Delay in starting treatment (21 patients) were found to be a major risk factor for development of pneumonia. More severe forms of H1N1 influenza are seen in tertiary care centre as evidenced by the occurence of ARDS and need for mechanical ventilation in H1N1 patients.

Severity assessment of CAP using scoring systems

Madhuri Gadithala, Sonali Trivedi


JLN Hospital and Research Centre, Bhilai, Durg, Chhattisgarh, India. E-mail: madhuri.g1005@gmail.com

Aim and Objective: Study of confusion, urea, respiratory rate, blood pressure, age>65 (CURB-65), pneumonia severity index, infectious diseases society of America/American thoracic society (IDSA/ATS) minor criteria in severity assessment of community acquired pneumonia in adults.

Materials and Methods: Prospective study in adults who had clinical and radiological findings of pneumonia. Vital parameters were measured, complete blood counts, arterial blood gases and biochemical profile, renal function tests, random blood sugar, electrolytes were done. Scoring systems were applied.

Results: In predicting ICU admission CURB 65 class ≥ III, PSI class ≥ IV and ≥ V, IDSA/ATS minor criteria had sensitivity (%) of 79.49, 95.65/67.39, 69.7 and specificity (%) of 75.41, 61.11/98.15, 100. In predicting death sensitivity (%) was 68.75, 100/78.12, 100 and specificity (%) of 75, 51.47/89.17, 50. PSI class IV was more sensitive for ICU admission and death but class V was more specific. Overall class V was good for prediction of both (kappa value = 0.67, 0.68) CURB 65 class ≥ III is moderate for prediction of site of care and outcome (kappa =0.53,0.41). IDSA/ATS was good in predicting site of care as it was 100% specific. Area under curve (AUC) for predicting mortality was highest for CURB 65 and for predicting ICU admission was highest for IDSA/ATS minor criteria.

Conclusion: Site of care decision is one of the most important things in management of patients with CAP. All the scoring systems were able to correctly identify high risk groups as there were no deaths or ICU admission from low risk groups. PSI class v was useful in deciding site of care and to predict outcome. CURB 65 class ≥ III was moderate in assessing both outcome and death but it was good in predicting mortality compared to PSI and IDSA/ATS. IDSA/ATS minor criteria was good for predicting site of care.

Clinical, microbiological profile in bronchiectasis

Sayantan Saha, Arunabha Datta Chaudhuri, Simit Kumar


R.G. KAR Medical College & Hospital, Kolkata, West Bengal, India. E-mail: nbmcjimi@gmail.com

Aim and Objective: (1) To identify the most common symptoms and signs in patients of bronchiectasis both during acute exacerbation and stable condition, (2) to study the microbiological profile in patients of bronchiectasis both during acute exacerbation and stable condition, (3) to identify the drug sensitivity of the pathogens in patients of bronchiectasis during acute exacerbation, (4) to study the spectrum of radiological findings in bronchiectasis, (5) to compare non-invasive (sputum) and bronchoscopic (BAL) techniques in identifying pathogens during acute exacerbation of bronchiectasis.

Materials and Methods: It is a descriptive, cross-sectional study where indoor and outdoor based patients of bronchiectasis have been included and evaluated clinically, radiologically and microbiologically.

Results: We studied 70 patients of bronchiectasis during acute exacerbation. These patients were subsequently followed up during stable condition. Majority of the bronchiectasis patients were female (60%) and belonged to age group 18 to 84 years. The most common symptoms during acute exacerbation were cough (92.86%) with mucopurulent expectoration (85.71%) followed by breathlessness (60%). Whereas that in stable condition was cough with mucoid expectoration. The most common type of bronchiectasis in HRCT thorax was cylindrical type followed by cystic type. The most common organisms during acute exacerbation were Haemophilus influenzae, Pseudomonas aeruginosa,  Moraxella More Details catarrhalis and Streptococcus pneumoniae. The same organisms were seen during stable condition.

Conclusion: This study aims to evaluate the clinical, radiological and microbiological profile of patients of bronchiectasis in a tertiary care hospital. It was opined that identification of proper organism play an important role in determining the treatment outcome and organism directed specific treatment is a key for successful therapeutic benefit.

A study of profile and outcome of CAP in HIV+ and HIV−

Joshua Sarella, V. Nooka Raju, N. Usha Rani, Y. Gayatri, P. Viritha


GHCCD, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: joshua.sarella@gmail.com

Aim and Objective: CAP is a major cause of morbidity and mortality in persons infected with HIV. The introduction of HAART has lead to a notable decline in opportunistic infections, however bacterial pneumonia becomes more prevalent. This study aims to evaluate and compare clinical profile and outcomes of CAP among HIV positive and HIV negative patients.

Materials and Methods: 66 consecutive patients who had clinical and /or radiological evidence of pneumonia, both HIV positive and negative, with no history of antibiotic treatment in the previous 15 days were selected. The study period is between June 2014 and August 2015. Patients with a presumptive or definitive diagnosis of PJP, mycobacterial and fungal pneumonia were excluded. All the patients underwent investigations like sputum gram staining C/S, AFB staining, CBC. Blood chemistry, CXR, HIV testing, CD4 counts and other tests selectively. Patients were managed as per ATS /IDSA guidelines for CAP.

Results: Of the selected 66 patients 50 were immunocompetent and 16 were HIV+ve. The mean age of HIV+ve patients with CAP was 38.94 yrs and that of HIV-ve was 48.9 yrs. The mean leucocyte count was 9,400/mm 3 and 13,640/mm 3 in HIV+ve and HIV-ve groups respectively. Mean Hb% was 9.06 gms% in HIV+ve and 10.98 gms% in HIV-ve patients. The commonest organisms isolated were Streptococcus pneumonia followed by Klebsiella and Pseudomonas. The average time of clinical stability (TCS) in HIV+ve cases was 3.63 days and 3.56 days in HIV-ve cases. The average length of hospital stay (LOH) in HIV+ve group was 7.88 days and 8.58 days in HIV-ve patients. Out of 66 patients 4 deaths occurred.

Conclusion: The clinical, radiological presentations and TCS were almost similar in both the groups except that HIV+ve group presented at younger age. HIV infected patients have low Hb% and total leucocyte counts. The LOH was slightly higher in HIV-ve group.

Refractory asthma: Aspergillus in broncho-alveolar lavage significant?

Shyam Krishnan, Tarang Kulkarni, Samim Khan, Raja Dhar


Fortis Hospital, Kolkata, West Bengal, India. E-mail: drshyam83@gmail.com

Aim and Objective: Aspergillus spp. are ubiquitous fungi causing a spectrum of pulmonary diseases depending on the immune status. During the past one year we encountered a set of patients with refractory wheeze, who grew Aspergillus spp. in their bronchoalveolar lavage and responded clinically to antifungal therapy. The aim of this study was to establish an association between Aspergillus growth and the refractory wheeze, while highlighting the relevance of performing a bronchoalveolar lavage and promptly initiating voriconazole therapy in this set of patients.

Materials and Methods: The period of study was for 1 year. All the patients with suspected obstructive airway disease having refractory bronchospasm not responding to standard asthma therapy had HRCT done, followed by bronchoscopy with broncho-alveolar lavage (BAL), where indicated. Patients who grew Aspergillus spp. were treated with the standard dose of voriconazole. Post-discharge spirometry and a through clinical evaluation were performed during follow up.

Results: 27 of BAL samples sent for fungal culture showed growth of Aspergillus sp. (92.5% grew Aspergillus fumigatus). Average time to positivity was 3.9 days. 23 of the patients were inpatients (5 in ICU's) and 4 outpatients. Male:females 15:12. Mean age of the patients was 62 ± 7 years. 48% (n=13) had diabetes mellitus, 33.3% (n=9) had an underlying heart disease, 22% (n=6) had a history of pulmonary tuberculosis. 74% (n=20) had HRCT changes of new infection. 81% patients responded very well to the treatment, as assessed by post discharge spirometry, clinical evaluation and quality of life. The overall mortality was 19%.

Conclusion: A high index of suspicion is needed for Aspergillus infections in patients with obstructive airway disease presenting with severe bronchospasm not responding to asthma treatment. Bronchoscopy should be performed in such patients and BAL sent for fungal culture among other investigations. Voriconazole therapy is indeed useful to achieve control over the refractory bronchospasm. A bigger prospective study would be needed to clarify whether this is a variant of pulmonary aspergillosis, not described previously.

Detailed spectrum of aspergillosis in treated TB

Shubhra Jain


Institute of Respiratory Diseases, Jaipur, Rajasthan, India. E-mail: shubhrajainap@gmail.com

Aim and Objective: This study includes the detailed clinical, radiological and microbiological profile of all culture positive cases of pulmonary aspergillosis detected in 6 months from January 2015-June 2015 at our tertiary care centre.

Materials and Methods: A hospital based observational study was conducted to study the clinical and microbiological characteristics of patients with aspergillosis. Treated patients of pulmonary tuberculosis having symptoms of persistent cough and or hemoptysis were enrolled after exclusion of active tuberculosis by Xray chest and sputum AFB. Patients whose respiratory specimen showed isolation of aspergillus were included in study. Demographic details, predisposing factors and clinical finding were recorded. Sputum was sent for KOH mount and fungal culture. Xray chest and CT chest was done in all patients.

Results: 20 patients were enrolled with male:female ratio-2:3. Mean age was 35 year. The most common symptom was hemoptysis followed by cough with expectoration and chest pain. Mean duration of symptoms were one year. Mean time of history of anti tubercular treatment was 5 year. Xray chest alone missed diagnosis in almost 70 percent of patients. All clinically suspected cases were confirmed by CT chest and fungal culture. Out of 20 cases 12 were diagnosed as aspergilloma and 8 were diagnosed as chronic necrotizing pulmonary aspergillosis. Most common species identified was Aspergillus fumigatus. Other species isolated were Aspergillus tereus, niger and flavus.

Conclusion: An early suspicion and diagnosis of pulmonary aspergillosis is essential in treated pulmonary tuberculosis patients to prevent further dissemination. In our study most common diagnosis was aspergilloma followed by CNPA in treated cases of pulmonary tuberculosis.

Bacteriological profile of VAP in tertiary care

Hanumanth Mali, Laxmanbabu, Venu Kandala, K. Yugaveer, Deepika, P. Pradeep


Kamineni Institute of Medical Sciences, Nalgonda, Telangana, India. E-mail: hanumanthmali06@gmail.com

Aim and Objective: The objective of this study is to know the causative organism and antibiotic sensitivity pattern of the isolated bacteria in our ICU at tertiary care hospital.

Materials and Methods: A prospective cohort study was conducted over one year six month period in our ICU. All the patient on mechanical ventilation for > 48 hrs with clinical pulmonary infection score > 6 were enrolled under present study. Patients with pre existing pulmonary infection at the time of admission/chest trauma/evidence of sepsis at admission were excluded. Endotracheal aspirate samples were collected. Quantitative culture threshold of >105 cfu/ml is considered to diagnose VAP. Out of the 46 cases enrolled quantitative culture threshold of >105 cfu/ ml were obtained from 42 patients, bacteriological spectrum and sensitivity pattern studied in these patients.

Results: Out of 42 patients 33 (78%) cases were males, 17 (40%) cases fell with in the age group of 61-80 yrs, 12 (29%) organo phosphorous cases developed VAP followed by 8 (19%) of cases COPD and DM each, 33 (79%) cases were developed late onset VAP. 14 (34%)cases were culture positive for Pseudomonas spp. followed by Klebsiella 11 (27%) and Acinetobacter spp. 11 (27%). Most of the gram negative organism were sensitive to colistin (100%) polymyxin-b (100%) and meropenam (93%) followed by piperacillin tazobactum (80%). Most of the gram positive organisms were sensitive to vancomycin (100%) and linezolid (100%).

Conclusion: VAP are common in ICU settings particularly in tertiary care hospitals. Higher age, OP poisoning, COPD and DM were important risk factors for developing VAP with male preponderance. In late onset VAP gram negative organisms were common with highest sensitivity to colistin, polymyxin-b and meropenam. In early onset VAP gram positive organisms were common with highest sensitivity to vancomycin and linezolid.

Multiplex polymerase chain reaction - An innovative diagnostic tool

Poulomi Chatterjee, Naveen Kumar, Bornali Data, Pinky Goyal


Medanta - The Medicity, Gurgaon, Haryana, India.

E-mail: poulomi.chatterji@gmail.com

Aim and Objective: To establish the utility of multiplex PCR testing as a rapid diagnostic tool for respiratory infections, enabling targeted therapy of specific pathogen.

Materials and Methods: Methods: We conducted a prospective, observational, sequential case series of patients pre-senting with respiratory infections from 01/12/2014 to 07/02/2014. These patients underwent bronchoscopy and bronchial washings which were sent for multiplex polymerase chain reaction (PCR) and culture sensitivity.

Results: 60 consecutive patients were taken in the study. 42 (70%) were males and 18 (30%) were females. Of the patients with risk factors for respiratory infections, 45% were diabetics, 40% had COPD, 15% had CKD and 6.7% were post transplant patients (kidney, liver, stem cell). 23 (38%) patients had a positive yield on multiplex PCR and 11 (18%) had a positive yield on culture sensitivity. There was a sensitivity of 95% and specificity of 79%. Klebsiella pneumoniae Scientific Name Search  was the most common organism isolated. In addition CMV was isolated in 5 patients (8%) and influenza were isolated in 5 patients (8%), pneumocystis jiroveci isolated in 3 patients (5%).

Conclusion: We conclude that multiplex PCR is as sensitive as culture sensitivity. Rapid results allow earlier commencement of targeted antibiotic therapy, which lead to better outcomes. An additional benefit is detection of infective viral pathogens and pneumocystis carinii. Multiplex PCR has an important role as a rapid diagnostic tool in respiratory infections.


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Acute exacerbations and cognitive functions in chronic obstructive pulmonary disease

Dipti Agarwal, Sushma Sood, Prem Parkash Gupta


Departments of Physiology and Respiratory Medicine, PGIMS, Rohtak, Haryana, India. E-mail: adipt@ymail.com

Aim and Objective: To assess cognitive functions using event related potential, P300 in COPD patients with frequent acute exacerbations and to compare with cognitive functions in COPD patients who had infrequent acute exacerbations.

Materials and Methods: In present study, 92 hospital based eligible COPD patients, diagnosed as per GOLD guidelines, were included. These patients were incorporated into 2 groups on the basis of acute exacerbations during preceding one year: Group 1 (FECOPD Group) included 48 patients who had ≥ 2 exacerbations, and Group 2 (I-FECOPD Group) included 44 patients with < 2 exacerbations. Event related potential P300 was used to assess cognitive functions. We used oddball paradigm, acoustic stimuli were presented by tone burst method.

Results: The mean age of patients in FECOPD group and I-FECOPD group was 62.58±9.61 year and 55.80±11.12 year, respectively. Mean exacerbations in both groups were 2.98±1.25 and 0.55±0.730, respectively. FECOPD group and I-FECOPD group differed significantly with respect to duration of illness (21.73±5.53 year vs. 17.07±5.22 year), FEV1 (1.270±0.247 L vs. 1.711±0.306 L) and PEFR (247.04±49.40 L/m vs. 335.32±61.15 L/m). Mean P300 latency was significantly increased in FECOPD group compared to I-FECOPD group (330.45±18.64 ms vs. 303.06±15.71 ms); there was no statistically significant difference between two groups regarding mean P300 amplitude (4.82±2.95 ΅V vs. 4.89±6.47 ΅V). P300 latency correlated directly with number of exacerbations, age, duration of illness and clinical scores. P300 correlated inversely with spirometric indices and there was no correlation with smoking pack years. Regression model showed frequent acute exacerbations being the strongest predictor of increase in P300 latency.

Conclusion: P300 is widely used for assessment of cognitive functions. In present study, P300 latency was prolonged in COPD patients with frequent acute exacerbations group. P300 latency correlated with exacerbations, age, duration of illness and spirometric indices. Frequent acute exacerbations parameter was the strongest predictor of cognitive impairment.

Value of serum clusterin in the assessment of chronic obstructive pulmonary disease

Shradha Soni, P. R. Gupta


NIMS University, Jaipur, Rajasthan, India.

E-mail: sonishradha@gmail.com

Aim and Objective: This study was undertaken to assess the value of serum clusterin (SC) as a biomarker for the assessment of cognitive dysfunctions in COPD.

Materials and Methods: The COPD patients were grouped as category A TO D on the basis of risk assessment. Ten normal age and sex matched subjects served as controls. Hindi Mental State Examination (HMSE) questionnaire was used as a gold standard. SC levels were measured in all of them using quantitative sandwich enzyme immunoassay technique.

Results: A total of 75 COPD patients and 10 age and sex-matched controls, could be recruited during the study period. The basic parameters of these subjects were similar but the mean duration of illness was higher and the mean HMSE scores, lower in category D patients as compared to the rest (p160. The mean SC values were also the highest in category D (p<.0001). PB FEV1 correlated directly with SC levels, as were the sPO2.

Conclusion: Estimation of SC is a useful tool in assessing the cognitive impairment in COPD.

Defective bacterial phagocytosis in nonsmoker chronic obstructive pulmonary disease

Baishakhi Ghosh, Bill Brashier, Jyoti Londhe, Kanchan Pyasi, Sundeep Salvi, Peter Barnes, Louise Donnelly


Symbiosis International University, Chest Research Foundation, Pune, Maharashtra, India and NHLI, United Kingdom. E-mail: bghosh226@gmail.com

Aim and Objective: Our previous research on monocyte-derived macrophages (MDMs) from tobacco-smoke induced COPD (TS-COPD) subjects had shown defective bacterial phagocytosis. However, it is not known whether the same defect is observed among nonsmoker COPD (NS-COPD) subjects. We aimed to investigate whether there is impairment in bacterial clearance by MDMs in NS-COPD.

Materials and Methods: Monocytes were derived from peripheral venous blood from 34 healthy non-smokers (H-NS), 15 healthy smokers (H-S), 19 tobacco-smoke associated COPD (TS-COPD) subjects, and 40 non-smoker COPD (NS-COPD) subjects. The monocytes were cultured with granulocyte-monocyte colony stimulating factor (GM-CSF) containing complete media for 14-18 days to obtain MDMs. MDMs were incubated with fluorescently-labelled, polystyrene beads (50X10^6 beads/mL), heat-killed Streptococcus pneumoniae (SP: 1.2X 10^9 CFU/mL) and  Haemophilus influenzae Scientific Name Search I:1.5X10^8 CFU/mL). Intracellular uptake of SP and HI by MDMs were measured by fluorimetry and viability of MDMs was measured by MTT assay.

Results: There were no differences in phagocytosis of polystyrene beads by MDM from any subject groups. Significant reduced phagocytosis of SP and HI in MDMs from TS-COPD compared to H-S subjects (SP: P<0.0001 and HI: P=0.0021) and NS-COPD compared to H-NS (SP and HI: P<0.0001). Although there were no significant difference in phagocytosis of SP and HI among the TS-COPD compared to NS-COPD. Viability of MDMs from any subject groups was not affected.

Conclusion: Defective phagocytosis of macrophages is observed in non-smoker COPD subjects, which is further evidence that there is a common susceptibility mechanism as that of tobacco-smoke associated COPD subjects.

Systemic inflammation leading to co morbidities in chronic obstructive pulmonary disease

Nitin Jain, N. K. Jain, A. Sharma, A. Chaturvedi


IRD Jaipur, Jaipur, Rajasthan, India.

E-mail: jainndr@gmail.com

Background and Objective: Chronic obstructive pulmonary disease (COPD) has been recently recognized as a condition involving more than the lungs and has extra pulmonary effects that seems to be related with systemic inflammation. Metabolic syndrome is more likely to be present in COPD patients and increase levels of pro-inflammatory proteins from both the lung and adipose tissue coincide in these patients. Presence of metabolic syndrome in COPD patients frequently results in increased possibility of pulmonary arterial hypertension (PAH). The aim of current study was to investigate the frequency of metabolic syndrome and PAH and their association with C-reactive protein (CRP) levels, as a marker of systemic inflammation in COPD patients.

Materials and Methods: Total 288 patients, 200 males and 88 females of COPD were included in the study diagnosed on the basis of GOLD criteria. Metabolic syndrome was diagnosed on basis of international diabetes federation (IDF) ethnicity specific criteria. CRP levels and 2D-Echocardiography was done to assess systemic inflammation and PAH respectively.

Result: Among 288 patients with COPD 104 (36.11%) patients had metabolic syndrome. PAH was found in 120 (41.66%). 160 (55.56%) patients had positive CRP levels and out of 120 patients of PAH, CRP was positive in 80 (66.66%). In 104 patients of metabolic syndrome, CRP was positive in 84 (80.76%) while PAH was present in 68 (65.38%).

Conclusion: In our study 36.11 % patients with COPD had coexisting metabolic syndrome and 41.66% had PAH. The study shows that coexisting metabolic syndrome with COPD is associated with increase in levels of systemic inflammatory markers and altogether results in PAH.

Classification of chronic obstructive pulmonary disease by Global Initiative for Chronic Obstructive Lung Disease 2006 and 2011 criteria

Richa Mittal, Sunil K. Chhabra


Vallabhbhai Patel Chest Institute, New Delhi, India. E-mail: mitricha@gmail.com

Aim and Objective: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 guidelines on management of COPD classified the severity into four stages based on FEV1. GOLD 2011 guidelines recommended a multidimensional scheme classifying the severity into four groups (A, B, C, D) by combining symptoms evaluation using the modified Medical Research Council (mMRC) grading or the COPD assessment test (CAT), and exacerbation risk assessment using spirometry stage or number of exacerbations/hospitalizations. We compared the distribution of patients and examined the extent of discordance between the two criteria.

Materials and Methods: The study was approved by the Institutional Ethics Committee. In the outpatient setting of a tertiary care hospital, 400 consecutive stable patients with a diagnosis of COPD were included after informed consent. mMRC grading of dyspnoea and CAT scores were assessed followed by spirometry. Distribution of patients by the two criteria was compared using chi square test and Kappa agreement was evaluated.

Results: The frequency distribution according to the GOLD 2006 criteria was 9%, 39%, 42% and 10% in Stages I to IV, respectively. With GOLD 2011 mMRC classification the distribution in groups A to D was 7%, 31%, 4% and 58% respectively and with GOLD 2011 CAT, it was 9%, 29%, 4% and 58%, respectively. There was a significant discordance between GOLD 2006 and 2011 classifications (p <0.001), the latter shifting patients into more severe groups with majority being in group D. There was poor agreement in the distribution of patients by GOLD 2006 and 2011 classifications, either using mMRC or CAT score (kappa 0.26 and 0.22, respectively).

Conclusion: The present study shows that there is a significant discordance and poor agreement between GOLD 2006 and 2011 classifications of severity of COPD with more patients getting categorized into higher severity groups by the latter. This has implications in management.

Renal function reserve in chronic obstructive pulmonary disease by Doppler indices

Abhishek Prakash, Bharat Bhushan Sharma


S.M.S. Medical College, Jaipur, Rajasthan, India. E-mail: abhipmch@gmail.com

Aim and Objective: Abnormal renal functional reserve may herald fall in baseline GFR and rise in plasma creatinine. Our main objective was to assess the renal pulsatility index (PI) and renal resistivity index (RI) among severe COPD cases. We also aimed to assess a correlation between above indices and spirometry and other parameters

Materials and Methods: This was a hospital based observational study having a case - control design done in Department of Medicine, S.M.S Medical College, Jaipur. A total of 50 patients with 25 severe COPD patients (no exacerbations in last 6 weeks, no resting hypoxemia - SpO2 < 88%) as cases and an equal number of age and gender matched controls were included. A detailed history, clinical examination, relevant investigations and procedures were done.

Results: We found a significant difference between cases and control groups as regards FEV1, FVC, and FEV1/FVC ratio. Baseline/fasting PI (0 MIN) before protein loading in cases was 1.8 ± 0.4 while in controls it was 1.1 ± 0.1 and the difference was statistically significant (p< 0.05). Upon comparison of PI with each individual study parameter in cases, we found that it had a linear relationship (Pearson's correlation) with other PI values, RI values and PEFR. Upon comparison of RI with each individual study parameter in cases, we found that it had a relationship (Pearson's correlation) with other RI values, FVC and FEF 25-75.

Conclusion: Our study throws a light on the less studied relationship between renal function impairment and COPD. Studying renal vascular resistance before and after protein loading may help to identify COPD patients with potential risk in developing progressive renal damage. To the best of our knowledge, renal functional reserve measurement using RI and PI has not been done previously in Indian population.

BODE, DOSE or ADO, predicts best in chronic obstructive pulmonary disease outcome

N. K. Rajathilakam, T. P. Rajagopal, P. T. James, K. P. Suraj, P. T. Anandan, Kiran Vishnu Narayan


Institute of Chest Diseases, Kozhikode, Kerala, India.

E-mail: rajathilakamnk@gmail.com

Aim and Objective: (1) To determine which of three multidimensional assessment systems BODE, DOSE or ADO is superior in predicting COPD exacerbations, (2) classify patients into different severity groups as per GOLD 2013 criteria, (3) describe the outcomes in terms of exacerbation or death, (4) to evaluate factors associated with exacerbations.

Materials and Methods: This was a prospective cohort study conducted in the OPD or immediately prior to hospital discharge and followed up monthly for 1 year from January 2014 to June 2015. PFT, 6MWD, mMRC dyspnea scores, Oxygen saturation levels, body composition, comorbidities, smoking status, age, and GOLD staging, were analyzed, and predictions of exacerbation by the three assessment systems were compared. Statistical analysis was done using SPSS version 18.

Results: Of 300 patients 4% lost follow 8% died during the study period. 20.7% in group B and 79.3% in group D of 2013 GOLD staging criteria. The mean annual exacebation rate was 2.42 events per patients per year. Death and rate of exacerbation correlated significantly with lower FEV1, lesser 6MWD, higher MMRC dyspnea score, GOLD stage D, higher DOSE, BODE and ADO index. For prediction of exacerbation the AUC were larger for BODE.

Conclusion: These composite scores BODE, DOSE, and ADO can also be used to assess outcome in COPD in Indian patients. BODE index was a better predictor of COPD exacerbation when compared with DOSE and ADO index.

Pulmonary artery pressures and quality of life in chronic obstructive pulmonary disease

Binil Salam Ma, Athira Prasannan, P. Hari Lakshmanan, K. Akhilesh, Asmita Mehta, P. T. James


Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail : dr.binilsalam@gmail.com

Aim and Objective: Correlation between pulmonary artery pressure and quality of life (QOL) in patients with COPD. Secondary objectives: other predictors of QoL in COPD and that of pulmonary artery (PA) pressures in COPD.

Materials and Methods: 100 patients diagnosed with COPD as per GOLD guideline, in a tertiary hospital during August 2011-December 2014, were included in the study. The baseline characteristics of the population, BODE index, QoL by SGRQ score and PA pressures were assessed.

Results: 74.3% were males while 25.7% were females. The QoL correlated with PA pressures (r: 0.709; p ~0.001). Variables that correlated with SGRQ scores were previous hospitalizations (r: 0.407; p~0.001), BODE index (r: 0.692; p~0.001), baseline oxygen saturation (r: -0.419; p~0.001) and 6MWD (r: -0.551; p~0.001). Other than QoL, the following variables correlated with PA pressures: Duration of COPD (r: 0.293), previous hospitalizations (r: 0.388), BODE index (r: 0.548), baseline oxygen saturation (r: -0.452) and 6MWD (r: -0.364).

Conclusion: PA pressures had significant correlation with SGRQ score. Since the main aim of various interventions including rehabilitation in COPD is improving the QoL, identifying and targeting the factors which affect the same as in this study, is very important to evaluate and improve the outcome measures.

Microalbuminuria prevalance and chronic obstructive pulmonary disease severity

J. Sujay, G. S. Gaude, Jyothi Hattiholi


Jawaharlal Nehru Medical College, Belgaum, Karnataka, India. E-mail: suyoga163@gmail.com

Aim and Objective: To study the prevalence of microalbuminuria in patients with COPD and its relationship with severity of the disease.

Materials and Methods: In a tertiary care hospital, 50 COPD patients were enrolled. All patients underwent clinical evaluation and pulmonary function test. The presence of microalbuminuria was defined as urinary albumin creatinine ratio (UACR) being ≥20 in men and ≥30 in women. Oxygen saturation (SpO2) was measured by pulse oximeter. Associations were estimated using Pearson linear coefficients. Logistic regression analysis was performed to estimate the relative risk of abnormal UACR.

Results: The prevalence of MAB was 30%. The prevalence of MAB in GOLD stage 3 was16.6% and in stage 4 was 54%. Pearson correlation analysis showed that there were a significant inverse relationship between UACR and SpO2 (r: -0.48, p: 0.0003), FEV1% (r: -0.37, p: 0.006). In logistic regression model, the presence of microalbuminuria showed a significant relationship with SpO2 (p: 0.0007).

Conclusion: Microalbuminuria is seen in patients with COPD, depending on the severity of disease. Since it is a predictor of cardiovascular events and all-cause mortality, patients with MAB should undergo examination at regular intervals for risk of cardiovascular morbidity or mortality.

Home based pulmonary rehabilitation in chronic obstructive pulmonary disease

Dipti Gothi, Mayank Saxena, Ram Babu, Kartik Sood, Nishith Kumar


SGPGI, New Delhi, India.

E-mail: mayank.saxena.doc@gmail.com

Aim and Objective: To evaluate improvement in 6 minute walk test (6MWT), BORG scale, AQ20 score with home based pulmonary rehabilitation.

Materials and Methods: A prospective randomized case-control study was carried out at two centers over 5 years that included 91 COPD patients. The randomization ratio was 2:1 with 2 in case and 1 in control group. 6MWT BORG scale, BODE index and AQ20 were noted at baseline, intervals of 15 days and end of 3 months. The home-based rehabilitation program consisted of isotonic and isometric exercises (walking, climbing stairs, getting up from squatting position, pushing wall) at home in two sessions each for 30 minutes.

Results: Age (mean ± SD) range was 65.09 ± 7.286 and 59.20 ± 8.71 years (p=0.06) in control and case group respectively with male: female ratio of 30:1. The case and control groups were matching in terms of FEV1, AQ20, BORG scale and BODE index whereas the 6MWT was significantly higher (p=0.004) in control compared to case group. The 6MWT in case had improved significantly from 282 ± 101.6 to 394.2 ± 89.89 meters (p=0.0001) at the end of treatment. Whereas, in control 6MWT had not improved i.e. 342.8 ± 75.85 meters at baseline and 352.4 ± 70.98 meters at the end of treatment (p=0.07). BORG in case at baseline and end of treatment was 6.085 ± 1.557 and 3.673 ± 1.1875 respectively. AQ20 in case at baseline and end of treatment was 13.88 ± 2.986 and 8.473 ± 0.421 respectively. Both BORG scale (p=0.0001) and AQ 20 (p=0.0006) had improved significantly compared to control group.

Conclusion: Home based pulmonary rehabilitation is useful in improving the quality of life. It is significantly cheaper, more feasible and viable option especially in COPD patients where hospital based or supervised program is not feasible.


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GAP assessment system in idiopathic pulmonary fibrosis at a tertiary center

Unnati Desai, Vinaya S. Karkhanis, Jyotsna M. Joshi


TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India. E-mail: unnati_desai82@yahoo.co.in

Aim and Objective: Idiopathic pulmonary fibrosis (IPF) is a progressive idiopathic interstitial pneumonia with poor prognosis. GAP is a prognostic staging system for IPF. We studied the utility of GAP index in our IPF patients

Materials and Methods: Retrospective observational study was conducted at a tertiary care center after Ethics Committee permission. Fifty consecutive IPF patients were included in study. Baseline clinical characteristics, comorbidities, spirometry, arterial blood gas (ABG), six-minute-walk-distance (6MWD), pulmonary hypertension were noted. GAP index constituted scores for: G-gender (male:1, female:0), A-age (less than/equal to 60:0, between 61-65:1, more than 65:2) and P-lung physiology variables (FVC, >75:0, 50-75:1, 55:0, 36-55:1, <=35:2, cannot perform:3). GAP scores of 0-3, 4-5, 6-8 were classified as GAP stage I, II, III respectively. The survival of patients at 1, 2 and 3 years was confirmed telephonically. Percentage mortality was calculated for various GAP stages.

Results: Study group consisted of 22 men and 28 women. Mean age, forced vital capacity (FVC%), 6MWD, PaO2 were 61.58+10.8 years, 1.39+0.69 liters (51.94+16.63%), 266+107 meters, 66+13 mmHg respectively. GAP stages I, II, III consisted of 7, 20, 23 patients respectively. Mean GAP index averaged 5.2+1.56. The 1 year, 2 year, 3 year mortality was 14.3%, 28.6%, 28.6% in GAP I; 40%, 55%, 60% in GAP II and 56.5%, 82.6%, 95.7% in GAP III respectively. Various comorbidities like GERD (46%), osteoporosis (38%), hypertension (20%), ischemic heart disease (14%), diabetes mellitus (12%), psychiatric illness (18%), obstructive sleep apnea (10%) and metabolic syndrome (8%) were noted. Amongst patients died at 3 year, moderate to severe pulmonary hypertension (mean PAP-64 mmHg), delayed presentation (>1 year), comorbidities, 6MWD< 50 % was noted in 100%, 69%, 68%, 87%, 81%, 86% respectively.

Conclusion: Pulmonary hypertension could be incorporated in future IPF prognostic scores.

Idiopathic pulmonary fibrosis: Study of 46 patients

Subramanian Natarajan, Poonam Subramanian


The Lung Centre and Jupiter Hospital, Thane, Maharashtra, India. E-mail: cnsubu@gmail.com

Aim and Objective: Idiopathic pulmonary fibrosis (IPF) is the commonest form of ILD diagnosed all over the world as well as in India. The objective was to study the clinical presentations, treatment options and survival of patients diagnosed as IPF.

Materials and Methods: This was a six year retrospective observational study. All patients diagnosed as ILD underwent a comprehensive evaluation to confirm the diagnosis of IPF and included in the study. Clinical data and laboratory data were recorded. Patients were treated as per current guidelines.

Results: Total patients: n= 46 (37.4%). Males, n=19 (41%) and Females, n=27 (59%). 67% of the patients were in the 61 to 80 age group (n=31). Mean age in males was 68.36 and in females was 66.25 years. Clubbing was seen in 67% (n=29). The mean forced vital capacity (FVC) was 52%. Desaturation on six minute walk distance was noted in 60% of patients (n=28). HRCT Chest showed definite UIP pattern of honeycombing in 60% of patients (n=28). Desaturation on six minute walk distance was noted in 60% of patients (n=28). Ten patients wrongly received anti tuberculosis (TB) treatment (21%) before they were diagnosed as IPF. The survival was 20% (n=2) in patients given Anti tuberculosis medications while it was 50% (n=08) in patients not given Anti tuberculosis medications [P value 0.05]. The median delay in diagnosis was 20 months. The five year survival rate was 25%, average survival being 39 months. Patients receiving pirfenidone showed a survival benefit as compared to those having received triple therapy. At the end of three years, survival estimates showed 75% survival in pirfenidone group as compared to 40% survival in triple therapy group, but no difference in either groups at the end of four years. Survival in IPF was significantly low as compared to other ILDs. Twenty four patients died during the study (52%).

Conclusion: Idiopathic pulmonary fibrosis is a disease which affects fourth to seventh decade of Indian population with low survival.

Clinical and functional profile of idiopathic pulmonary fibrosis patients

S. K. Humayun Kabir, Shelly Shamim, Subhra Mitra, A. G. Ghosal


Calcutta National Medical College, National Allergic Asthma Bronchitis Institute, Kolkata, West Bengal, India. E-mail: humayun195@gmail.com

Aim and Objective: To study clinic-radiological and functional profile of idiopathic pulmonary fibrosis (IPF) patients at the time of diagnosis and at 6 month follow up. Thereby to monitor rate and variability of progression in different patients. And also to asses the effectiveness of intervention.

Materials and Methods: It is a prospective study of clinical finding, imaging (HRCT), and functional (forced vital capacity FVC, 6 minute walk distance 6MWD, oxygen saturation SPO2) parameter of 30 diagnosed patients of IPF. These parameters are re-assesed at 6 month follow-up and comparision done with statistical analysis. Disease progression is defined as decreasing of FVC more than 10% from base line.

Results: Most of the IPF patients are male (n=22, 73%), smoker (n=23, 80%) with median age of presentation in males 65 yrs±10, and in case of female it is 52 yrs±9. Most common clinical features at presentation are dyspnea (93% of patients with duration of 12.5 months±5.38), cough (90% of patients with duration of 14.6 months±6.6), bi-basilar crepitation (100%) clubbing (50%). on functional parameter evaluation results are FVC 1.52L±0.5, 6MWD 275m±84, SPO2 94%±3. Frequency of associated co-morbidites are GERD (66%), hypertension (26%), diabetes (26%), ischemic heart disease (23%). Comparing the followup parameter after 6 month it is evident in our study that majority of patients (80%) show no progression during study period. However male and smoker population show progression of disease. This finding is statisticaly significant with p value 0.0017 and 0.001 respectively. Patients who received irregular treatment show no significant change (p = 0.018) in disease progression. It is also evident that there is no change of disease progression radiologicaly during study period. Study shows 6MWD co-relate poorly with FVC change.

Conclusion: IPF patients mostly remains static over a period of 6 months. Male and smoking are two risk factor associated with disease progression. Treatment has no impact on disease progression over 6 month window. Screening should be done to find out co morbid conditions. 6MWD is a poor tool for disease monitoring.

Study of cardiovascular dysfunction in interstitial lung disease

Archana Malik, Raunak Das, T. Mohanty, J. Patnaik, M. R. Pattanaik, H. K. Sethy


S.C.B Medical College, Cuttack, Odisha, India.

E-mail: drarchanamallick@gmail.com

Aim and Objective: To study the clinical manifestations and echocardiographic patterns of cardiovascular dysfunctions. To measure urine microalbumin and serum NT-proBNP. To correlate the degree of albuminuria and serum NT proBNP with echocardiographic and HRCT findings of patients of ILD.

Materials and Methods: A prospective study constituting 60 cases of ILD admitted to Department of pulmonary medicine, SCB MCH Cuttack, excluding cases of active pulmonary TB.

Results: Age range was 26-83 with male (55%) and female (45%). Chief complains: dyspnea on exertion is the most common symptom followed by dry cough. Most common sign was Velcro rales followed by tachypnea. Many had habit of tobacco chewing including males and females but no alcoholic or smokers in females. Diabetes was the most common comorbid condition observed. Lab parameters: Raised ESR was the most common abnormality (76.67%), hypoalbuminemia (66.67%), Raised serum NT proBNP (63.33%), microalbuminuria (48.33%). Spirometry: FVC< 60 (70%), > 60 (30%). Chest x ray-bilateral lower zone (45%) followed by diffuse (41%). HRCT pattern: Septal thickeninig (56.6%), nodules (50%). Honeycombing (46%), types: UIP (31.67%), OLD (28.33%), NSIP (23.33%), HP (15%), AIP (1%). 2D ECHO- normal (43.33%), PAH with TR (40%), diastolic dysfunction (13.33%)

Conclusion: The prevalence of cardiovascular dysfunction especially PAH is high in ILD patients and 2D ECHO can detect mostly moderate and severe variety of PAH. But cardiovascular biomarkers like raised serum NT proBNP and microalbuminuria may play an important role in predicting the presence of mild form of cardiovascular dysfunction so that treatment could be initiated early in ILD patients and may improve their survival.

Study of spirometry, diffusing capacity of lung for carbon monoxide and 6 minute walk test in interstitial lung disease patients

Sindhoora Rawul, Prasad E. Chelluri


Department of Pulmonology, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: dr.sindhoora.rawul@gmail.com

Aim and Objective: The study aims at determining the association between abnormal spirometry, DLCO (diffusing capacity of lung for carbon monoxide), 6MWT (6 minute walk test) in patients with features of interstitial lung disease presenting to the Chest Clinic of Shadan Institute of Medical Sciences.

Materials and Methods: The study presents 1 year cross-sectional observational data. 46 ILD suspects participated. 19 patients were diagnosed as ILD's. All the patients were evaluated clinically, radiologically (HRCT), hematologically, serologically and biochemically. Respiratory examination, Spirometry, DLCO (Easy Pro One) and 6MWT were performed as per the ATS Guidelines.

Results: Forty six consecutive subjects (male=26, female=20) participated. 20 males were smokers. 37 (80%) patients were abnormal on various pulmonary function tests. Mean age 56.4 ± 13.7 years. Nineteen were diagnosed as ILDs; IPF=11 (58%) and collagen etiology=8 (42%). 17/19 (89%) had restrictive defects on spirometry which were categorised as mild, moderate, severe. In mildly (n=4) restricted: FVC (%pred.) 72.75±5.00, DLCO (%pred.) 32±25.30, KCO (%pred.) 82.75±18.09, 6MWT (meters) 278.75±85.67. In moderately (n=4) restricted: FVC (%pred.) 56.75±6.99, DLCO (%pred.) 39.25±15.04, KCO (%pred.) 84.5± 10.40, 6MWT (meters) 347.5± 131.49. In severely (n=9) restricted: FVC (%pred.)40.77±5.47, DLCO (%pred.) 25.44±8.05, KCO (%pred.) 66.11±22.55, 6MWT (meters) 197.55±52.14. Statistical analysis revealed both variables i.e., FVC and DLCO, move in same direction. DLCO, KCO and 6MWT were lower in the severe group.

Conclusion: DLCO, KCO, 6MWT were lower in the "severely restricted" ILD subjects. The major limitation is our small number.

Cyclophosphamide in systemic sclerosis related interstitial lung disease

Priya Jayarajan, K. P. Suraj, T. P. Rajagopal


Institute of Chest Diseases, GMC, Kozhikode, Kerala, India. E-mail: drpriyajayarajan@gmail.com

Aim and Objective: To analyse the effectiveness of cyclophosphamide pulse therapy in patients diagnosed to have systemic sclerosis (SSc) associated interstitial lung disease (ILD) in a tertiary care centre. Secondary objective was to study the various adverse effects of therapy.

Materials and Methods: The study was conducted in Institute Of Chest Diseases, Government Medical College, Kozhikode.34 consecutive patients with the diagnosis of SSc associated ILD who met the inclusion criteria and treated with 12 cycles of 500 mg cyclophosphamide intravenously once in 4 weeks during the period January 2011 to July 2014 were included and further followed up for one year after completion of treatment. All patients underwent spirometry and 6 minute walk test (6MWT) before the start of therapy and then every 6 months and were monitored for any side effects of treatment.

Results: There was statistically significant improvement in 6MWD and forced vital capacity (FVC) values following cyclophosphamide pulse therapy. No serious adverse events were noted.

Conclusion: This study, though has limitations with regard to sample size, shows that cyclophosphamide pulse therapy is effective in treatment of SSc associated ILD with good tolerance. However, large randomised control trials are required for validation.

S.LDH as a predictor of adverse outcome in interstitial lung disease

Ann Mary Jacob


Government Medical College, Thiruvananthapuram, Kerala, India. E-mail: hiashwindavid@gmail.com

Aim and Objective: The objective was to determine whether serum LDH can predict adverse outcome among ILD patients (IPF and non IPF) as measured by fall in FVC >10% or fall in DLCO >15% or mortality at the end of 6 months of follow up.

Materials and Methods: 66 consecutive diagnosed cases ILD, 30 IPF and 36 non IPF were enrolled. Serum LDH, FVC, oxygen saturation, distance covered in 6 minute, DLCO, HRCT findings, collagen vascular disease profile were the study variables. The outcome variables were fall in FVC, DLCO at the end of 6 months follow up or death.

Results: 90% of IPF and 69% of Non IPF were > 50 years of age and the male to female ratio was 1:3 and 2:7 respectively. Overall adverse outcome was recorded in 63% of IPF and 33% of non IPF (p<0.05). Fall in FVC was 9% in IPF and 8% in non IPF (p> 0.05). Fall in DLCO was 9% in IPF and 8.6% in non IPF (p< 0.001). Death was the outcome in 33 % in IPF and 8% in non IPF (p<0.01). Mean serum LDH was 288 (SD-38) in IPF and 253.5 (SD- 37) U/L in non IPF (p<0.01). Predictive power of LDH for adverse outcome was established at 270 in total 66 patients with a sensitivity and specificity of 77 and 86%, 275 in 30 IPF patients with sensitivity and specificity of 74 and 91% and 242 in 36 non IPF patients with a sensitivity and specificity of 92 and 75%.

Conclusion: LDH is a sensitive biomarker of cell injury and can be applied to predict short term prognosis in ILD; especially in resource limited settings.

Spirometry and 6MWT in pneumoconiosis patients

U. G. Deepak, Vinod Joshi, K. C. Agarwal


Dr. S. N. Medical College, Jodhpur, Rajasthan, India.

E-mail: deepakug17@gmail.com

Aim and Objective: To assess the correlation of Spirometry and 6MWT in pneumoconiosis patients according to ILO guidelines.

Materials and Methods: A descriptive study conducted at Dr. SN medical college Jodhpur, India from July 2013 to August 2014. Total of 109 patients were selected on the basis of history of exposure to silica, chest x-ray was used to confirm the diagnosis of silicosis and to classify them according to ILO guidelines. Spirometry and 6 MWT was performed by each patient. Pearson Chi-square test and welch ANOVA was used for statistical analysis.

Results: FEV1/FVC ratio, FEV1, FVC of patients with grade 1/0 and 1/1 was 97.15±7.1, 91.15±8.9%, 93.3±6.4% respectively and these parameters were within normal limits and these spirometric variables gradually decreased with increasing ILO grading and decreased to 62.5±22.6, 36.25±14.2% and 60±18.42% respectively in grade C of PMF patients, all these change in parameters were highly significant.

Conclusion: Along with chest x-ray, spirometry and 6MWT, both are simple and non-invasive but highly useful in assessing the severity of silicosis and functional capacity in silicosis patients because both Spirometry and 6MWT correlate well with ILO grading of chest X-ray.


   Interventional Pulmonology Top


Bronchopleural fistula localisation

Ravi Shankar, H. G. Varudkar, J. C. Agrawat, Sunil Mukati, Swapnil Jain, Sourav Khosla


R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India. E-mail: dr.ravimishrapulmo@gmail.com

Aim and Objective: Comparisons of feasibility, sensitivity and complication of three different methods viz. methylene dye, selective bronchography and balloon temponade.

Materials and Methods: This article reports experience of diagnosing BPF using methylene blue dye in five patients, by selective bronchography under C-arm control by using non-ionic dye in 18 cases and by balloon tamponade in 25 cases. In methylene blue technique, suspected segments was instilled with methyelene blue dye and another physician observed through pleuroscope leaking of dye. Selective bronchography under C arm control. Fiber optic bronchoscope was passed and a balloon catheter was negotiated through it to segment. Balloon was distended and radio opaque dye (Iodoxanol 1cc) was instilled. Video recording was done. Dye was aspirated back and saline wash was done to clear the segment. Balloon was deflated and then other segments were subjected to same procedure. The involved segment showed 1) scattered dye 2) poor retrieval of dye. In rest of the segments all these signs were not seen. In Balloon tamponade, fiber optic bronchoscope was passed first into the upper lobe bronchus, balloon was inflated and patients was asked to cough and bubbles were observed in under water seal drain. It was followed by occluding the individual segment and bubbles were seen in under water seal drain. Similarly intermedius bronchus then middle lobe and lower lobe bronchus was occluded followed by occluding individual segment and BPF was localized by confirming absence of bubbles in under water seal drain by occluding the individual segment.

Results: The site of BPF was identified in one patient by methylene blue technique, in three cases by selective bronchography with non ionic dye and in Eight cases by balloon tamponade method.

Conclusion: 1) BPF was convincingly proved in less than 50% cases via all methods. 2) Most convincing method for BPF localization is with Balloon tamponade method.

Endobronchial ultrasound with real-time transbronchial needle aspiration rapid on site evaluation aided cell block preparation

Umang C. Shah, Nevin Kishore, Nitin Dayal, Palak Brahmbhatt


Max Superspeciality Hospital, Saket, New Delhi, India.

E-mail: dr_umangshah@yahoo.co.in

Aim and Objective: Conventional smears of samples obtained by endobronchial ultrasound with real-time transbronchial needle aspiration (EBUS-TBNA) have proven useful in lung cancer staging, but the value of additional information from cell-block processing of EBUS-TBNA samples has only been marginally investigated. The purpose of this study is to assess the role of 'Rapid On Site Evaluation' (ROSE) in the diagnosis of pulmonary/mediastinal pathologies, while performing EBUS TBNA with evaluation of cell blocks processed from EBUS TBNA samples in obtaining additional clinically relevant information such as immunohistochemistry and molecular testing.

Materials and Methods: This study is performed on twenty patients who underwent EBUS TBNA for diagnosis of hilar/mediastinal lymphadenopathy or lung mass adjacent to a central airway. The sample collected from needle aspiration was smeared and processed with rapid staining for ROSE. Based on the initial findings cell blocks were generated from the cytology needle samples, which were utilized for the morphological diagnosis. The possible uses of cell blocks for immuno-histochemistry and ancillary molecular testing were also analyzed whenever needed.

Results: In our study we found adenocarcinoma (10), squamous cell carcinoma (4), lymphoma (2), non-small cell carcinoma (1) and other tumors (3). Adequate cell blocks could be obtained in 70% of cases (14/20), which were used for morphological characterization and IHC studies. In 78.6% (11/14) cases, the cell block provided a subtype specific pathological diagnosis with relevant IHC. Four cases of pulmonary adenocarcinoma underwent molecular testing and showed positive EGFR/ALK mutations.

Conclusion: Performance of immediate on-site cytologic interpretation and assessment of adequacy by the cytopathologist can be time-consuming but significantly improves the diagnostic yield. ROSE during EBUS TBNA definitely lowers the need for additional bronchoscopic procedures and puncture number. It also confirms the adequacy of specimen for cell block, which can be used for immunohistochemical staining and ancillary molecular testing for the better classification of neoplasms and hence reduces the further need of conventional biopsy procedures in Lung cancer.

Application of bedside USG in thoracic diseases

Arnab Bera, Susmita Kundu, Sumit Roy Tapader


R. G. KAR Medical College, Kolkata, West Bengal, India.

E-mail: arnab1988_doc@yahoo.in

Aim and Objective: 1. Bedside detection of pleural/pericardial effusion, pneumothorax,consolidation 2. Guidance for diagnostic thoracocentesis, pleural biopsy, ICD. 3. Bedside detection of peripheral lung mass and guided FNAC or trucut biopsy from the lesion.

Materials and Methods: This study was carried out in Indoor patients admitted in RCU and general ward of department of pulmonary medicine, R. G. Kar Medical College with suspected thoracic diseases.102 cases of general ward patients and 66 of RCU patients were examined by USG and 98 patients underwent USG guided various interventions. Exclusion Criteria - a. Patient unwilling to give consent. b. Abnormal coagulation profile in case of intervention. Methods of Data Collection - Interview of patients or relatives for baseline data. Bedside USG of thorax. FNAC or Biopsy report of mass lesions. Experiment Design - A descriptive, observational study.

Results: Amongst patients admitted in RCU, by USG most common abnormality found is pleural effusion (39.13%),followed by pneumonia, pneumothorax and in general ward, most common abnormality found is pleural effusion (40.96%), followed by peripheral lung mass, pneumothorax. USG is more sensitive than CXR in detecting pleural effusion and pneumothorax but less sensitive in detecting pneumonia and lung mass in our study and overall time gain by USG before CXR for diagnosis is 12-24 hour. USG guided pleural fluid aspiration done in 45 patients, pleural biopsy in 13, ICD in 33,FNAC in 18 and trucut biopsy in 5 patients. Among USG guided procedure success rate of trucut biopsy is 100% followed by FNAC 88.89% and pleural biopsy 61.54%. Pnemothorax developed as a complication in 5 of pleural tapping, 2 of pleural biopsy and 2 of FNAC patients and hemoptysis in 1 of FNAC and 1 of trucut biopsy patients.

Conclusion: USG of the chest is useful in the evaluation of a wide range of peripheral parenchymal, pleural, chest wall and cardiac diseases and is increasingly used to guide interventional procedures of the chest. Advantages include portability permitting bedside examination, time gain before diagnosis by CXR and relatively safe procedure.

EBUS-TBNA in diagnosing intrathoracic lymph nodes

Tanushree Gahlot, Ujjwal Parakh, Kusum Verma, Bobby Bhalotra


RBTB Hospital, Sir Ganga Ram Hospital, New Delhi, India. E-mail: tanushree.gahlot@gmail.com

Aim and Objective: To assess the clinical usefulness and safety profile of Endo Bronchial Ultrasound-guided Trans Bronchial Needle Aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy.

Materials and Methods: Observational prospective study of 100 adult patients with mediastinal and hilar lymphadenopathy who underwent EBUS guided TBNA with Aspirate obtained from the most hypoechoic lymph node (with a 22-gauge needle in 3 passes) and its histopathological analysis, patients observed for intraprocedure and post procedure complications.

Results: Out of 100, 92 cases were reported as adequate (diagnostic yield=92%), amongst these 92, there were 71 (77%) granulomatous lymphadenitis (tuberculosis=41 (44.5%), sarcoidosis=30 (32.2%)). Malignancy was reported in 16 (17.3%) patients and 5 (5.43%) were reported to have reactive changes. There was one case each of mycobacterium avium Scientific Name Search  complex and mycobacterium abscessus. Out of 16 cases of malignancy, 6 were adenocarcinoma, 4 of squamous cell carcinoma, 2 cases of small cell carcinoma. There were 3 cases of Hodgkins lymphoma and 1 case of Non-Hodgkin lymphoma. No complications were noted in 44 % patients, however fever (26%), nausea (20%), mild bleeding (4%), bronchospasm (3%) and intraprocedure hypoxia (2%) were the minor complications that were noted.

Conclusion: EBUS-TBNA is highly accurate (diagnostic yield 92%) and safe procedure for diagnosing intrathoracic (mediastinal and hilar lymphadenopathy) lymphadenopathy and can diagnose granulomatous inflammation with a high efficacy.

Balloon dilatation in idiopathic tracheal stenosis

Baranitharan Manoharan, Vinod Aiyappan, Phan T. Nguyen, Hubertus Jersmann, Peter C. Robinson


Royal Adelaide Hospital, Flinders Medical Centre, Belfast, UK. E-mail: baranitharan23@yahoo.in

Aim and Objective: To study the effectiveness of flexible bronchoscopic balloon dilatation for the treatment of idiopathic tracheal stenosis.

Materials and Methods: Retrospective single centre study.

Results: 12 consecutive patients diagnosed with ITS and treated with flexible bronchoscopic balloon dilatation between 2008 to 2015 were included in the study. All 12 patients were female. The average age was 50 years (Range: 29-77). The average time between the onset of symptoms and diagnosis was 26 months (Range: 4 months - 6 years). Pulmonary function data could be traced for only 6 patients out of which 5 patients showed fixed extrathoracic airway obstruction. One patient's report did not have a flow volume loop. Flexible bronchoscopy showed proximal stenoses in the majority of cases (11/12 i.e., 92%). The majority (11/12 i.e., 92%) of the stenoses were circumferential in appearance with or without web formation. Balloon dilatation was effective in increasing the tracheal lumen and improving symptoms in all (100%) of the patients. All patients tolerated the procedure well and there were no significant complications. 50% (i.e., 6/12) patients required repeat dilatations. The average number of dilatations were 3.25 (range: 0-11). The average interval between repeat procedures was 16 months (range: 3 to 22 months).

Conclusion: Flexible bronchoscopic balloon dilatation is a simple, safe and effective procedure for the treatment of patients with idiopathic tracheal stenosis. Ongoing monitoring is required to identify patients requiring repeat balloon dilatations.

Comparison of brush cytology and BAL in lung tumors

Mithilesh Kiran Kulkarni, Dilip Mhaisekar, Vijay Kapse


Dr Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India. E-mail : drmithileshkk@gmail.com

Aim and Objective: To compare the yield of brush cytology and bronchoalveolar lavage cytology in suspected lung neoplasms.

Materials and Methods: The present study was carried out at Dr. S.C.G.M.C. Nanded, Maharashtra. Patients suspected of having lung tumors were admitted, bronchoscopy done and samples were collected. Comparison of yield of brush cytology and Bronchoalveolar Lavage cytology was done. The statistical test (chi-square test) was applied to test the significance.

Results: Out of 50 patients brush cytology yielded 40 (80%) to be malignant (Adeno carcinoma 50% and squmous cell carcinoma 30%) as compared to BAL cytology which yielded 15 (30%) to be malignant (Adeno carcinoma 20% and Squamous cell carcinoma 10%) which was found to be statistically significant (p < 0.05).

Conclusion: Brush cytology has better diagnostic yield as compared to Broncho Alveolar Lavage cytology in patients suspected of having lung tumors.

Bronchial artery embolisation

Monika Maheshwari


J.L.N. Medical College, Ajmer, Rajasthan, India. E-mail: opm11@redifmail.com

Aim and Objective: To check efficacy and safety of Bronchial Artery Embolisation (BAE) as an alternative to invasive surgical procedure for control of massive haemoptysis in patients coming in emergency department.

Materials and Methods: It was conducted at Jawahar Lal Nehru Medical College and Associate Group of Hospitals, Ajmer. Total 20 patients with massive (>500 ml) haemoptysis and recurrent haemoptysis (>3-4 episodes/week) were subjected to Bronchial artery Embolisation (BAE). Cobra-type curved catheters were used for catheterization of the bronchial arteries. After catheterization of the bronchial arteries, bronchial angiography is performed with manual injection of non-ionic iso-osmolar contrast medium. Angiographic findings in massive hemoptysis included hypertrophic and tortuous bronchial arteries, neovascularity, hypervascularity and extravasation of contrast medium. Absorbable gelatin sponge was then used as embolic material to plug the bleeding vessel because it has a controllable embolic size, is inexpensive and easy to handle.

Results: Bronchial artery embolisation (BAE) was very effective in controlling acute massive hemoptysis. Immediate success rate was 90%. However, long-term recurrence rates was found in 17.2% cases. Post procedure chest pain was complained by 34% patients. Oher complications like dysphagia, bronchial artery dissection and spinal cord ischaemia reported in literature following BAE were not encountered by us.

Conclusion: Bronchial artery embolization (BAE) is a safe and effective nonsurgical treatment for patients with acute massive hemoptysis. Knowledge of bronchial artery anatomy, together with an understanding of the pathophysiologic features of massive hemoptysis, are essential for performing BAE. BAE is a palliative procedure that does not address the underlying disease but rather treats the symptom acutely and prepares the patient for elective surgery for localized disease or continued antimicrobial therapy with reduction in associated morbidity and mortality.

Is medical thoracoscopy a reliable investigation?

Mahendra Kumar Bainara, Manoj Arya


TBS Hospital Bari, RNT Medical College, Udaipur, Rajasthan, India. E-mail: mkbainara@gmail.com

Aim and O bjective: To find out the diagnostic yield of thoracoscopic pleural biopsy and to assess the accuracy and safety of thoracoscopy for evaluation of undiagnosed exudative pleural effusion.

Materials and Methods: Prospective analysis of data of 79 patients who underwent thoracoscopy for confirmative diagnosis of undiagnosed exudative pleural effusion "between" April 2011 to April 2015. Safety and complications of procedure were also analyzed.

Results: The overall diagnostic yield of thoracoscopic pleural biopsy was 81% (64/79) in patients of undiagnosed exudative pleural effusions. Pleural malignancy was diagnosed in 54.43% (43/79) of patients, Tuberculosis in 26.58% (21/79), non specific inflammation in 18.99% (15/79). Among the pleural malignancies metastatic adenocarcinoma was found in 44.19% (19/43) patients, malignant mesothelioma in 25.58% (11/43) patients, squamous cell carcinoma in 16.28% (7/43) patients, benign mesothelioma in 11.63% (5/43) patients. There was no major complication, only four patients had minor complications (three had subcutaneous emphysema and one patient had post operative fever).

Conclusion: Medical thoracoscopy is a semi-invasive and valuable tool in the diagnosis of undiagnosed exudative pleural effusion with minimal complication rate (5.06%). This procedure is very helpful in improving in quality of life of patients as therapeutic work can also be done with the procedure.

Yield of various techniques in FOB for lung cancer

G. S. Rajawat, Roopam Sehajpal, Amardeepak Toppo, Thomas Kurian, G. S. Yadav, Suresh Koolwal


SMS Medical College, Jaipur, Rajasthan, India.

E-mail: dr.govindsrajawat@gmail.com

Aim and Objective: To study the comparative yield of Bronchial Biopsy, Brushing and washing in lung malignancy.

Materials and Methods: In this retrospective study, a total of 148 patients with proven diagnosis of lung malignancy, in whom bronchoscopy was done and bronchial biopsy, brushings and washing were taken, were included. Comparative yield of the various techniques was evaluated.

Results: The yield of different techniques varied according to the type of malignancy, distance of the lesion from carina and size of the lesion. Bronchial biopsy had the maximum diagnostic yield (59.78%) followed by bronchial washing (52.21%) and bronchial brushing (43.6%). Bronchial biopsy had the highest yield (81.6%) in cases of small cell carcinoma, whereas brushing (50.78%) and washing (53.34%) had a higher yield in cases of squamous cell carcinoma. Combination of two or more techniques had higher diagnostic yield in comparison to single technique.

Conclusion: It is concluded that a combination of diagnostic techniques including bronchial biopsy, brushing and washing provides a higher yield of diagnosis of malignancy when compared to individual technique. Thus, bronchoscopists should adopt all diagnostic techniques for better yield.


   Lung Tumors Top


Lung cancer - a study at a tertiary care hospital

Rohit Ratnakar Hegde, Priti Meshram, N. N. Ramraje, J. M. Phadtare, Sudipto Dasgupta


Department of Pulmonary Medicine, Grant Government Medical College, Mumbai, Maharashtra, India. E-mail: rohit_hegde1984@yahoo.co.in

Aim and Objective: To study the clinical profile of lung cancer patients presenting to tertiary care teaching hospital.

Materials and Methods: All patients attending our department who were diagnosed as lung cancer were included in the study. All these subjects underwent investigations including complete blood counts, blood biochemistry, chest X-ray PA view and sputum cytology. CT thorax was done in all these patients with upper abdominal cuts. These patients were subjected to bronchoscopy and/or percutaneous fine needle aspiration biopsy (FNAB) under CT guidance. Data of 100 patients was collected and retrospectively analysed.

Results: Males were more commonly affected with mean age of 57.2 years and mean age in females being 54.6 years. 68% of patients were smokers It was observed that squamous cell carcinoma was more common in smokers and in centrally situated lesions Adenocarcinoma was more common in females, non smokers and in peripherally situated lesions. Majority of patients presented with a mass with or without collapse. Bronchoscopy with washings/biopsy was diagnostic in 62% of patients, especially in those with central endobronchial lesions. CT guided FNAB was diagnostic in 90.47% of patients having peripherally situated tumours. Majority of patients were in an advanced stage of disease at time of diagnosis.

Conclusion: Males and smokers were more commonly affected. Squamous cell carcinoma was more common in smokers and in centrally situated lesions. Adenocarcinoma was more common in females, non smokers and in peripherally situated lesions. Bronchoscopy with washings/biopsy and. CT guided FNAB were important diagnostic modalities used. Majority of patients were in an advanced stage of disease at time of diagnosis.

Prevalence of EGFR mutation in lung adenocarcinoma

Anitha Jacob, B. V. Murali Mohan, Mohammed Zuhaib, Syed Tousheed, Santosh Gowda


Narayana Health, Bengaluru, Karnataka, India.

E-mail: anithajacob2013@gmail.com

Aim and Objective: Despite tremendous progress in the last decade, lung adenocarcinoma remains a cancer with an unfavourable prognosis. Detection of genetic mutations especially EGFR and their subtyping which influence choice of targeted therapy is the current standard of care. Testing for these mutations is now mandatory. To study the prevalence of EGFR mutation and subtypes in patients with lung adenocarcinoma.

Materials and Methods: Retrospective study conducted by chart review of patients with lung adenocarcinoma over two years (2012-2014) in the Department of Pulmonology, Narayana Hrudayalaya, a tertiary care centre in Bangalore. 45 patients of predominantly South Indian origin with a diagnosis of adenocarcinoma lung were assessed for the presence of EGFR mutations and their subtypes. The EGFR mutations were checked with ARMS and Scorpion RT-PCR technique.

Results: Among 45 patients who were studied 23 (51%) had EGFR mutation. EGFR mutations were found in 12 males (41%) and 11 females (68%). Exon 19 mutation (16, 69.5%) was the most common mutation in both sex followed by exon 21 (8, 34%) and exon 18 (3, 13%). There were no exon 20 mutations. Double mutations were found in 4 patients.

Conclusion: The prevalence of EGFR mutations in our study was significantly higher compared to the global data (10% in US and 35% - 50% in Southeast Asia) and large scale studies are needed to further confirm this observation. Our study found a female predominance, with the most common mutation being exon 19 deletion, which is in accordance with global findings. From the data, a good response to treatment with tyrosine kinases inhibitors could be predicted to the extent of 51%. Clearly there are population differences, but the exact reason for the difference in EGFR prevalence between our patient population and western data is unknown but it gives us hope of relatively improved survival with targeted therapy.

Efficacy of Gefitinib in EGFR mutated Adeno Carcinoma lung

D. Senthil, Deepak Kumar, Paulo Akkara, George D. Souza, Priya Ramachandran, Uma Devaraj


St. Johns Medical College, Bengaluru, Karnataka, India.

E-mail: dsenthil.smile@gmail.com

Aim and Objective: To study the response of Tyrosine Kinase Inhibitor - Gefitinib in patients with Non Small Cell Lung Carcinoma - Adeno Carcinoma.

Materials and Methods: Subjects with histopathological diagnosis of NSCLC - Adeno carcinoma on Gefitinib therapy from 2013 till 2015 were evaluated retrospectively and response to drug evaluated in OPD visit/Phone call.

Results: Of 86 patients evaluated with Histopathological diagnosis of Adeno Ca, EGFR positive were 80 [93.02%] and Negative were 6 [6.97%], of which TKI given in 74 [92.5 %]. Out of the 33 patients in follow up 23 patients [69.7%] had more than 6 months survival, 82.6 % were non smokers. Secondary outcome evaluated was the adverse events.

Conclusion: Patients with newly diagnosed advanced adenocarcinoma of the lung with their cancer tested positive for EGFR-activating mutations treated with TKI - Gefitinib will have better survival and quality of life.

Clinico-patho-radiological profile lung cancer

Laxman Kumar Soni, C. R. Choudhary, Gopal Purohit, Sunil Vyas


Dr. S. N. Medical College, Jodhpur, Rajasthan, India.

E-mail: luckyagroya@gmail.com

Aim and Objective: Lung cancer is commonest and most lethal cancer throughout the world and tobacco smoking still continues to be the leading cause of lung cancer worldwide. An increase incidence of lung cancer has been observed in India. The aim of this study was to find out the demographic and clinico-pathological and radiological profile of diagnosed lung cancer patients and its relation to smoking habit in area of western Rajasthan.

Materials and Methods: It's a retrospective study of 310 patients of histo-pathologically proven cases of lung cancer in our hospital from 2012 to 2015.

Results: Among 310 patients, male were 89.7% and female were 10.33%, out of them 83.2% were smoker. Among all patients only 18.0% were ≤50 years of age in which female patients were more than male (female 43.75% and male 25.89%). The most frequent symptom was cough (59.35) followed by chest pain (50.32) and the most common radiological presentation was mass lesion (30.96%), followed by collapse (30.22%). Squamous cell carcinoma (50.32%) was most common histopathological type followed by adenocarcinoma (32.9%). Adenocarcinoma was the predominate type below 50 years and sq. cell ca. common in age above 50 years. Smoking was still the major risk factor for lung cancer.

Conclusion: This study has shown smoking as the Principal risk factor in causation of lung cancer. There are many awareness programs running throughout India but results are not satisfactory. So proper implementation of these programmes should be done to educate people to quit smoking and thereby decreasing the incidence of lung cancer near future. There are also lack of screening of lung cancer and no proper programme in place, similar to cervical and breast cancer.

Surgical resection in lung cancer patients

Syed Basharath Mehdi, Carla Harris, Kimberley Su, Rajesh Shah, Ram Sundar


Wrightington, Wigan and Leigh NHS Foundation Trust and University Hospitals of South Manchester, Uk.

E-mail: syedbasharath@yahoo.com

Aim and Objective: Department of Health in UK has recommended that the maximum wait from urgent general practitioner (GP) referral to first treatment should be 62 days with a maximum wait of 31 days between diagnosis and first treatment for all cancers.

Materials and Methods: Data for 60 patients diagnosed as lung cancer in district general hospital and referred to cardiothoracic surgeons was analysed.

Results: The average duration from GP referral to lung OPD was 8 days. The interval between first appointments until completion of investigations was 15 days. The interval between referral to care plan is 40 days. The interval between decision to operate and discussion with patient to operation is 22 days. The average age for 33 patients who were operated was 68.6 with mean performance score of 0.64 (Range 0-2). Amongst the 27 non-operated patients, cardiothoracic surgeons deemed 10 patients as unfit for surgery, 6 patients declined surgery, and 5 patients had metastatic disease whilst 6 patients had other reasons for not being operated. Overall 12 patients were referred to high risk multidisciplinary team (MDT), of which 4 patients underwent surgery, 2 patients opted out and 3 were deemed high risk. 3 other patients demonstrated reduction in the size of lesion size, metastasis and progression of disease and therefore deemed inappropriate for surgical resection.

Conclusion: Surgical management of lung cancer poses significant challenges and it is particularly important to assess clinical and physiological parameters of patients. Half of the patients discussed in high risk MDT were offered surgery and the rest were deemed unfit, thus increasing the surgical resection rate.

A study on lung cancer with pleural effusions

S. Vidya, Subhra Mitra


Calcutta National Medical College and Hospital, Kolkata, West Bengal, India. E-mail: vippy08@gmail.com

Aim and Objective: To study the epidemiological, clinico-pathological profile of lung cancer patients presenting with pleural effusion. To analyse the pleural fluid characteristics, diagnostic yield of various procedures in such patients.

Materials and Methods: Institution based cross-sectional observation study of lung cancer patients presenting with pleural effusion in a tertiary care teaching hospital in Kolkata.

Results: A total of 30 patients were included in this study. Majority were in the age group of 50-70 years (median 55 years) (range 28-82 years). Male to female ratio was 1.1:1. Most common presenting symptoms were cough (83.37%), dyspnea (76.67%), loss of appetite and loss of weight (70%). Amongst males, 93% were smokers (current or former), 25% were users of smokeless tobacco and only 3% were never smokers as well as never users of smokeless tobacco. Among females patients, these categories constituted 28.57%, 28.57% and 42.86%, respectively. Pleural effusion was unilateral (on the same side as lung primary) in 93.37% cases and bilateral in 6.67% cases. Pleural fluid was lymphocytic (86.67%), exudative (100%) with low ADA (<40 U/L in 96.67%), cytology positive for malignant cells in 50% cases. Diagnosis was established by CT-guided FNAC in majority cases (63.33%), rest by peripheral lymphnode FNAC or biopsy (3.33%), bronchoscopy-guided biopsy (3.33%), blind FNAC (3.33%). The diagnostic yield of CT-guided FNAC, lymphnode FNAC or biopsy, bronchoscopy-guided biopsy was 100% and that of pleural biopsy was 60%. Most common histologic types of the lung cancer in these patients, in decreasing order of frequency, were Squamous cell carcinoma (53.33%) followed by Adenocarcinoma (36.67%), NSCLC (unclassified) (6.67%), Small cell lung carcinoma (3.33%).

Conclusion: Lung cancer patients with pleural effusion commonly presented at 50-70 years age, with cough, dyspnea, loss of appetite and loss of weight. Majority males were smokers while about 40% females were never smokers as well as never users of smokeless tobacco. Pleural effusion in most cases was unilateral, lymphocytic, exudative, with low ADA, cytology positive for malignant cells in 50% cases. Most common histologic type was Squamous cell carcinoma, followed by Adenocarcinoma.

Clinico-epidemiological profile of lung cancer

Manoj Kumar Panigrahi, Saka Vinod Kumar, Venugopal Jaganathan, S. Mathanraj, Narahari Narendra Kumar


AIIMS, Bhubaneswar, JIPMER, Puducherry, India.

E-mail : manoj_kp99@rediffmail.com

Aim and O bjective: There has been a renewed interest in lung cancer epidemiology owing to changing trend in histology with a relative increase in adenocarcinoma worldwide. However such a trend is not observed across India over the last six decades. Objective: To assess the commonest cytohistological type and overall presentation of lung cancer.

Materials and Methods: Cross-sectional study from January 2011 to December 2012 in the department of Pulmonary Medicine, JIPMER, Puducherry. All patients with cytohistological confirmation of lung cancer were included in the study. Patients demographic data and clinico-radiological manifestations were recorded in a predesigned proforma. Staging of NSCLC was done as per 7 th edition of TNM classification and SCLC was staged as either limited or extensive disease.

Results: A total of 125 patients [115 (92%) NSCLC, 10 (8%) SCLC] were diagnosed as lung cancer. Mean age of presentation was 55±9.62. Seven (5.6%) patients were ≤ 40 years. Ninety five (76%) were male. Overall 71 patients (57.72%) were smoker. Cough 110 (88%) patients, dyspnea 92 (73.6%) and chest pain 63 (50.4%) were the predominant symptoms. Most common histological type was adenocarcinoma in 67 patients (58.26%) followed by squamous cell (39 patients, 33.91%), undifferentiated (7 patients, 6.08%) and large cell carcinoma (2 patients, 1.7 %). Majority of NSCLC patients (71 patients, 61.73%) presented with stage IV disease followed by IIIB (17.39%), IIIA (12.17 %), IIB (5.21%) and IIA (3.47%). Nine out of ten with SCLC had extensive disease. Most non-smoker (73%) had adenocarcinoma where as equal proportions (41%) of smoker had squamous cell and adenocarcinoma each. Adenocarcinoma was five times more common in females than males and squamous cell carcinoma was 3.8 times more common than adenocarcinoma in smokers. Surprisingly 24 patients (19%) were treated as tuberculosis.

Conclusion: We found adenocarcinoma as the commonest type of lung cancer in southern India with a trend of diminishing male-female ratio.

Bronchogenic carcinoma: Clinicoradiological profile

Shivani Chaturvedi, Lokendra Dave, Nishant Srivastava, Swapnil S. Garde, T. N. Dubey, Ramakant Dixit


Gandhi Medical College, Bhopal, Madhya Pradesh, India.

E-mail: shivani.chaturvedii@gmail.com

Aim and Objective: Lung cancer is one of the most commonly diagnosed cancers worldwide. The diagnosis of Lung cancer requires assessment at several levels. This study was planned to analyze the various clinical, radiological and pathological characteristics of patients diagnosed with bronchogenic carcinoma in our geographical area.

Materials and Methods: This study was conducted on 300 patients presenting to our centre from 2008 to 2014. They were evaluated on the basis of history, clinical examination, imaging procedures (skiagram, CT scan, Ultrasonography of pleural space, mediastinum and abdomen), fiber-optic bronchoscopy (FOB), fine needle aspiration biopsy cytology (FNABC) of lung, lung biopsy and pleural fluid analysis with pleural biopsy etc. Patients were staged by TNM classification. Patients were also followed up monthly and at the end of one year.

Results: Over eighty percent patients were smoker two third being bidi smoker. Majority of patients had smoking index of more than 300. The total duration of illness was less than 3 months in half of cases, with weight loss and anorexia as the most common constitutional, Cough and chest pain most common cardinal respiratory symptoms. Most common physical signs were anemia and clubbing followed by cervical or axillary lymphadenopathy. The radio-imaging confirmed mass lesion and pleural effusion as commonest findings followed by consolidation. Special investigations like bronchoscopy and FNAC are having role in better diagnostic yield. Squamous cell carcinoma (42%) was commonest histological type followed by adenocarcinoma.

Conclusion: If diagnosis at an early stage, it can be easily treated and a significant increase in five year survival rate in non small cell lung cancer (NSCLC) can be achieved. Even small cell lung cancer (SCLC) with limited disease has an edge for the better prognosis. Hence the role of an early diagnosis of bronchogenic carcinoma is highly desirable which can lead to better management strategies and alleviate patients suffering to a great extent.

Geftinib in smokers with adenocarcinoma lung

Gayathri Mohan, E. Jyothi, K. P. Suraj, T. P. Rajagopal


Institute of Chest Diseases, GMC, Kozhikode, Kerala, India. E-mail: mgayatthri@gmail.com

Aim and Objective: Recent literature suggests that somatic mutations in EGFR gene are associated with better response to EGFR tyrosine kinase inhibitors in patients with non small cell carcinoma lung. Some, but not all studies, have pointed out that the mutations were more common in patients without a smoking history. This study aims to assess the progression free survival (PFS) and quality of life (QOL) in smokers and nonsmokers, with stage lV Adenocarcinoma lung with EGFR positive status who were started on Geftinib.

Materials and Methods: All the 89 patients considered were started on oral Geftinib 250 mg daily and assessed at 3 months interval for 1 year from the initiation of treatment. PFS was assessed on the basis of clinical and radiological response to treatment. QOL was assessed using ECOG Score.

Results: Of the 89 cases considered, 58 were males and 31 females. It consisted of 43 smokers with an average smoking score of 1050 and 46 non smokers. 61 were cases of pleural effusion. Male sex had greater disease progression (46.6%) when compared to females (16.1%) (p= 0.004). Our study observed that there was no clinically significant difference in the progression among Smokers (39.5%) and non smokers (32.6%) (p value =0.496). Only severe adverse event observed was pulmonary thromboembolism in one patient.

Conclusion: There was significant improvement in smokers and nonsmokers treated with Geftinib especially in quality of life. Progression free survival was comparable. EGFR mutation prevalence is comparable in smokers and nonsmokers contrary to available data. Our study directs towards the need for trials with larger sample size to assess EGFR mutation status in smokers and whether Geftinib is beneficial in smokers as well.


   Pft Top


PFT changes within 24 hours of thoracocentesis

A. P. Kansal, N. Kiran, Anand Kumar Bansal, Naresh Bansal, Baljit Singh Virk


Government Medical College, Patiala Punjab, India.

E-mail: hardik24091989@gmail.com

Aim and Objective: To assess the changes in pulmonary function test before and within 24 hours of thoracocentesis and to assess the correlation between amount of pleural fluid aspirated and changes in FEV1 and FVC.

Materials and Methods: 100 patients of pleural effusion were subjected to pulmonary function test before and within 24 hours of thoracocentesis. Patients were classified on the basis of Chest x-ray as mild, moderate and severe.

Results: In our study out of 100 patients, 81 were male and 19 female. Mean age of patients were 44 years. On the basis of chest x-ray 50%, 29%, 21% of patients were having mild, moderate and massive pleural effusion respectively. In mild pleural effusion, there was 13.68% improvement in FVC and 13.69% improvement in FEV1. In moderate pleural effusion, there was 26.51% improvement in FVC and 26.45% improvement in FEV1. In massive pleural effusion, there was 32.13% improvement in FVC and 29.65 % improvement in FEV1 which is statistically significant. There was significant correlation between amount of fluid aspirated and change in FEV1 and FVC.

Conclusion: From the above study it is advised to perform thoracocentesis in the patients of pleural effusion for the improvement of lung function and for symptomatic relief.

Study of lung function in liver cirrhosis patients

Raiya Sagar, Athavale Amita


Seth G. S. Medical College and K E M Hospital, Mumbai, Maharashtra, India. E-mail: sagarraiya@kem.edu

Aim and Objective: To assess lung function in diagnosed chronic liver disease patients. To correlate severity of lung function abnormalities with severity of chronic liver disease.

Materials and Methods: 50 patients of chronic liver disease, visiting tertiary care hospital for liver transplant underwent pulmonary function test after clinical evaluation and chest radiography. Various parameters like Forced vital capacity (FVC), Forced expiratory volume in one second (FEV1), (FEV1/FVC) ratio, Forced expiratory flow 75%-25% (FEF75%-25%), Maximum voluntary ventilation, Residual volume and total lung capacity, Diffusion capacity, Maximum static inspiratory and expiratory mouth pressure were studied. Oxygen saturation in sitting and supine position was monitored using finger pulse-oximetry. The data was collected and then assessed for the statistical significance with the help of SPSS software version 19 and Microsoft Excel 2010.

Results: A total of 50 patients with cirrhosis, 42 males and 8 females, were included in our study. The mean age of the patients was 45.1 +/- 10.9 years. Seven (14%) patient had obstructive lung function, 21 (42%) had restrictive lung function defect whereas 22 (44%) had normal lung function. Eight (16%) had Mixed defect. 21 (42%) had MELD score more than 20 also had restrictive defect on PFT which was statistically significant (P0.05). Twenty six (52%) had low MIP (P >0.05) and 11 (22%) had normal MIP (Maximum Inspiratory Pressure) Thirty one (62%) had low MEP (P >0.05) and 6 (12%) had normal MEP (Maximum Expiratory Pressure) Sixteen (32%) had reduced residual volume and 21 (42%) had reduced total lung capacity by helium dilution method which was statistically not significant. (P>0.05) Maximum voluntary ventilation (MVV) was low in 6 (12%). (P>0.05) On pulse-oximetry, 10 subjects had desaturation by 1% and 5 subjects had desaturation by 2% on changing position from supine to sitting (Orthodeoxia) (P>0.05).

Conclusion: Our pilot study of various lung function parameters, shows decline with increasing severity of chronic liver disease, of which some are statistically significant, However larger study may help to conclude significance of remaining parameters.

Comparison of MVV with existing equation

S. Maharaul Mashrutee, K. Patel Anand


G. M. E. R. S. Medical College and General Hospital, Ahmedabad, Gujarat, India. E-mail: mashrutimaharaul@gmail.com

Aim and Objective: To check whether or not the formula in use is applicable to Indian adults and to derive a regression equation for predicting MVV by using FEV1 that can be applied to the Indian population.

Materials and Methods: Methods: FEV1 and MVV were measured in 60 healthy adults (30 males and 30 females) who had a median age of 19 (range 17-24 years). Data for FEV1 x 40 were compared with the measured MVV values by using one-sample t-tests. A regression equation was derived for predicting MVV in Indian adults.

Results: The values MVV calculated on the basis of previous equations (MVV = FEV1 x 40) were significantly different from the MVV values measured in the subjects (p< 0.05). The predictive equation obtained by this study was MVV = FEV1 x 43.55 (adjusted r 2 = 0.727).

Conclusion: The relationship between the MVV and FEV1 of healthy Indian adults was found to be different than those described by equations put-forth earlier. These equations cannot be applied to healthy Indian subjects. The equation derived by this study is MVV = FEV1 x 43.55.

Breath-holding test-an alternative to pulmonary function test in chronic obstructive pulmonary diseases

P. Dhamodharan, Bhim Rao, A. Chitrakumar


Government Kilpauk Medical College, Chennai, Tamil Nadu, India. E-mail: damodarmmc@yahoo.com

Aim and Objective: (1) To determine the maximum voluntary apnea inspiration time (MVAIT) in patients with chronic obstructive pulmonary diseases (COPD). (2) To correlate the MVAIT with PFT to aid in the determination of pulmonary function.

Materials and Methods: We conducted a cross sectional study of patients with COPD attending our OPD during the month of August 2015. Spirometry was performed in them and the FVC%, FEV1% and FEV1/FVC% of predicted were measured and recorded. After PFT, subjects were asked to perform breath holding test. Maximum voluntary apnea inspiration time was recorded. Correlation was determined by Pearson's coefficient, ANOVA and Linear regression test.

Results: A total of 48 patients with chronic obstructive pulmonary disease with mean age (57.6±9.4) and median age of 59.5 met the inclusion criteria and were included in the analysis. MVAIT was found to be lower in all individuals tested (18.9±4.8). Positive and significant correlation was found between breath-holding time and FVC% (r=0.394; p=0.031), FEV1%(r=0.412; p=0.025), and FEV1/FVC%(r=0.425; p=0.029) respectively were found in patients with COPD. MVAIT levels of patients were categorized into groups. The mean difference in FVC in different groups of MVAIT was statistically significant (p<0.001) according to one way ANOVA (F=11.69). Post hoc Bonferroni test was done to compare the intergroup means.

Linear regression test was done to assess the relationship between MVAIT and FVC which showed that for every 5% decrease in MVAIT results in 6% decrease in FVC (standard coefficient beta=0.622) which was also significant at the 0.01 level (2-tailed) (p<0.001).

Conclusion: Since there is a linear correlation between MVAIT and FVC% in our study group of COPD patients, breath holding test can be used as a bedside pulmonary function test in evaluating sick COPD patients who are unable to perform spirometry.

Tobacco smoking and bronchial hyperreactivity

Sudipto Dasgupta, N. N. Ramraje, Priti Meshram, R. R. Hegde, J. M. Phadtare


Department of Pulmonary Medicine, Grant Government Medical College, Mumbai, Maharashtra, India. E-mail: suds333@gmail.com

Aim and Objective: To study the relationship between the Pack Years smoked and prevalence of Bronchial Hyper-reactivity (BHR).

Materials and Methods: The study was conducted in OPD of Grant Govt. Medical College, Mumbai. We included 50 asymptomatic cigarette smokers aged 20-50 years, with normal Serum IgE, Chest Imaging and spirometry. Subjects were administered a Bronchial Challenge Test, using Histamine to assess for BHR.

Results: Of the 50 patients, 9 patients were females (18%) and 41, males (82%). 17 patients smoked less than 5; 15 between 5-15; and 18, more than 15 pack years.33 patients (66%) had positive and 17 (34%), negative Bronchial Challenge Test. 7 (out of 17) patients with <5, 11 (out of 15) patients with 5-15 and 15 (out of 18) patients with >15 Pack Years had a positive BCT. Using the Fisher's Exact test, this was found to be significant, (p value: 0.029).

Conclusion: As the Pack Years smoked increase, the prevalence of BHR also increases. The number of smokers with a positive test at a given concentration of Histamine increased as the Pack Years smoked increased, though not found statistically significant.

COPD-6 device for detecting airway obstruction

Yogesh Thorat, Shweta Rasam, Sundeep Salvi, Rahul Kodgule


Chest Research Foundation, Pune, Maharashtra, India.

E-mail: yogesh@crfindia.com

Aim and Objective: To evaluate COPD-6 device for detecting airflow limitation and predicting clinical diagnosis.

Materials and Methods: Spirometry was performed by a standard (Koko) spirometer and COPD-6 device in 187 subjects (asthma=115, COPD=31, healthy=41) in randomized sequence by a well trained technician. All the tests were repeated after bronchodilation with salbutamol 400 mcg delivered by MDI with spacer. Clinical diagnosis was made based on history, examination, spirometry and if required body plethysmography, DLCO and chest X-ray. Sensitivity and specificity of COPD-6 device were studied against standard spirometry and final clinical diagnosis and cut-off for FEV1/FEV6 was obtained by receiver operating characteristic analysis.

Results: The best estimate for cut-off for FEV1/FEV6 for COPD-6 device was 0.75 with a sensitivity of 78% and specificity of 87% to detect airway obstruction compared to standard spirometer. Sensitivity and specificity for predicting clinical diagnosis oh healthy and obstruction (asthma/COPD) of standard spirometry and COPD-6 were similar.

Conclusion: FEV1/FEV6 ratio of 0.75 by COPD-6 device can reliably detect airflow limitation in asthma and COPD.

Restrictive spirometry pattern in healthy persons

Anurati Mehta, Karishma Bhatia, Vishisht Mehta, Sanjeev Mehta


Chest and Allergy Centre, Creighton University, Omaha, USA. E-mail: anurati.mehta@gmail.com

Aim and Objective: Morbidity and mortality from non-communicable respiratory diseases is increasing. While high risk populations such as drivers and traffic policemen have been studied, there is little data regarding PFTS of apparently normal individuals. We aim to study this.

Materials and Methods: Staff of a community hospital in west Mumbai underwent spirometry using NDD Easy-on-PC spirometer and Indian adapted norms.

Results: 87 respondents, 32.18% males. Nurses and ward attendants 68.9%, office staff 13.7% and lab staff 11.49%. Age (years) 20-30: 55.17%, 31-40: 18.39%, 41-50: 14.9%. Smokers 6.89% FVC ≤ 80% noted in 38% FEV1 ≤ 80% noted in 42.5 % FEV1/FVC < 70 noted in 3.45% FEV 25-75% ≤ 80% noted in 76%.

Conclusion: Recent data has revealed a significant portion of the population with abnormal spirometry characterized by decreased FEV1 and FVC but a preserved FEV1/FVC ratio. This has been referred to as the Restrictive Spirometry Pattern (RSP), GOLD unclassified, Preserved Ratio Impaired Spirometry (PRISm), or the nonspecific pattern (when accompanied by a normal TLC). RSP is associated with adverse cardiovascular outcomes as well as mortality and it may be an underappreciated cause of functional impairments and respiratory symptoms. To the best of our knowledge, ours is the first study to demonstrate, in a young, adult, non-smoking, apparently healthy, urban Indian cohort, evidence of extensive RSP. We have also demonstrated very poor mid expiratory flow rates, the significance of which is beyond the scope of this abstract. While there are many limitations to this survey, we feel we have uncovered a large hidden burden of potential respiratory illness.


   Respiratory Critical Care Top


To study profile and outcome of patient in RICU

Rishi Kumar Saini, V. K. Tiwari, Rajesh Agarwal, Amit Kumar


Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. E-mail: 2drrishisaini@gmail.com

Aim and Objective: The Intensive care unit (ICU) is characterized as the hospital in to a hospital. An ICU is a specialized unit of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment. The aim of this study was to determine the incidence, patient characteristics, Prediposing factors, reasons and outcome of admissions in the RICU of the Rohilkhand medical college and hospital, Bareilly (U.P).

Materials and Methods: For the practical approach of the study was used the analysis of 144 patients admissions in the RICU. The analysis included patients that were hospitalised in the RICU of Deptt. of pulmonary medicine of Rohilkhand medical college and hospital, Bareilly from May 2014 until May 2015.

Results: There were 144 admission during the study period. From the patients 102 were men and 42 were women. About 46% were referred from the Emergency Department and 40% of patients came from other ICU or other hospital. The most common complaints of patients was breathlessness (86.1%) and cough (68.02%). Most patients had admission in the ICU because of Respiratory disorders and age above 50 yrs (>65%) of patients and average ICU stay 4.5days. Pseudomonas is the most common organism isolates from RICU admissions. About 65% of patients showed response to Oxygen inhalational therapy but 23% patients were put on mechanical ventilator. As outcome more than 60% patients discharged from the RICU, 16% died and 15% patient discharged and refer to higher center.

Conclusion: Respiratory problems are the major reason for an RICU admission. Patients that are men and in the age 51-87 and smokers or exposed to biomass fuel smoke are at greatest risk of an RICU admission. Most common indication of admission was type II respiratory failure. Data showed appreciable improvement of about more than 60% of patients that were improved and discharged.

Noninvasive ventilator in respiratory failure

Nisarg Oza, Dhaval Prajapati, Ravish Kshatriya, Nimit Khara, Rajiv Paliwal, Satish Patel


Pramukh Swami Medical College, Karamsad, Gujarat, India. E-mail: nisuoza@gmail.com

Aim and Objective: To study outcome of Non-invasive ventilator (NIV) support in patients of Acute Respiratory failure.

Materials and Methods: It was an observational study of 5 years where 110 patients with acute respiratory failure requiring NIV were included in study. Demographic data, history, clinical examination, relevant investigations, and clinical outcome of all the patients were recorded in a per-structured Performa with cause of respiratory failure. Outcome was recorded as patients were improved and discharged or not improved required intubation followed by fatal outcome.

Results: Out of 110, there were 78 males with mean age of 64.24 years and 32 females with mean age of 56.59 years. We had 68 patients of COPD, 10 of Bronchial asthma, 25 of Pneumonia, 3 of Pulmonary Tuberculosis, 2 of Interstitial lung disease and 1 of Cor-pulmonale because of other respiratory etiology. Among them 81 patients were improved (74%) and 29 (26%) were not improved We have found that improvement in pH (p<0.00001), pCO 2 (p<0.00001) and pO 2 (p<0.001) after 24 hours of NIV support predicts successful outcome. Patients having Chronic Obstructive Pulmonary Disease (p<0.00001) as cause of acute respiratory failure have favorable outcome. Patients receiving invasive ventilator once NIV support fails had worst outcome (p<0.00001).

Conclusion: Favorable outcome of non invasive ventilator support can be predicted in patients with acute respiratory failure having COPD as underlying cause and improvement in ABG parameters like pH, pCO 2 , pO 2 after 24 hours of NIV support. Worse outcome can be predicted in patients who required invasive ventilator after failed NIV support.

Developing a new scoring system for critically ill

U. Binoy, K. Madhu, P. Ravindran, S. M. Nair


Cosmopolitan Hospital, Trivandrum, Kerala, India.

E-mail: binoyu27@yahoo.com

Aim and Objective: Currently available scoring systems are based on death as outcome measurement, with the rapidly advancing and evolving medical care this death as outcome measurement appears inadequate. To develop a new scoring system, not based on death as outcome measurement, which will make an early recognition of critical illness and help in prevention of turbulent hospital stay.

Materials and Methods: 200 cases of critically ill pulmonary patients admitted to Critical Care Unit/High Dependency Unit/Ward with or without multisystem comorbid illnesses. Clinical evaluation for 1. Fever 2. Cough 3. Dyspnoea 4. Temperature 5. Respiratory Rate 6. Heart Rate 7. Blood Pressure 8. Cyanosis 9. Sensorium. Laboratory Parameters 1. Total Leukocyte count 2. Blood Urea 3. Serum Creatinine 4. CRP (C-Reactive Protein) 5.Procalcitonin 6. Spo 2 7. ABG (Arterial Blood Gases) were recorded along with other detailed clinical and lab parameters which were repeated as often as required. Patients were followed up until discharge or death, recording the full course in the Hospital like 1. Requirement of Nasal Oxygen 2. Non Invasive Ventilation (BiPAP) 3. Invasive Ventilation.

Results: Multivariate analysis will be done to identify the more important 1.clinical parameters 2.laboratory parameters and 3.changing laboratory parameters and scores are allotted according to the importance of each parameter identified in the analysis. With this, cutoff values will be predicted for emergency room physician, for the ward physician and the critical care physician to prognosticate and to start necessary management strategies for the individual patients.

Conclusion: This newly developed scoring system is helpful in early detection at emergency/casualty level, ward level of patients likely to develop a more critical course of illness and hence aggressive management can be started early to prevent invasive ventilation and its consequences.

Study of Intravenous catheter related infections

Tinku Joseph, Tushar Sahasrabudhe, Vikas Oswal, Megha Oberoi


Department of Pulmonary Medicine, DR. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. E-mail: tinkujoseph2010@gmail.com

Aim and Objective: To look for the commonest organism isolated in IV catheter.

Objective: To assess the relationship with the duration of device in place and with IV steroid use.

Materials and Methods: A total of 146 patients admitted in Pulmonary Medicine ward and ICU were enrolled in study group. Detailed history of their diagnosis was obtained. The tip of the intravenous catheters were cut with sterile blade and collected directly into sterile autoclaved bulb sealed and sent to microbiology lab for gram stain, routine culture and sensitivity and Fungal stain and culture.

Results: Out of 146 IV devices sent for culture 51 showed growth of various microbes. IV catheter sent after access of 3 days showed 2 growth, 4 to 6 days showed 16 growth, >6 days showed 33 growth ( P<0.0001). Most common organism isolated was MRSA 13 (9.32%) followed by pseudomonas 6 (4.10%), MSSA 5 (3.42%), Enterobacter 5 (3.42%), Klebsiella 4 (2.74%). Surprisingly patients who were on IV steroids showed growth of Candida albicans 4 (2.74%).

Conclusions: (1) The growth of various Microbes in IV devices was directly proportional to the duration of device in place. (2) With these results we would strongly recommend change of IV devices in all patients after a minimum of 3 days to prevent development of nosocomial Infections.

Personalised care plans in patients with COPD

Priyada Pandya, Rajat Mathur


London North West Healthcare NHS Trust, UK.

E-mail: priyadapandya0@gmail.com

Aim and Objective: Patients with COPD in the United Kingdom often feel frustrated by their progress through the emergency department. During each admission they have to explain to the emergency room physician their baseline exercise tolerance, baseline arterial blood gases and if they are on home nebulisers or home oxygen. We decided to give our patients the chance to decide their ceiling of care. We have produced a patient passport which gives our patients the chance to have improved quality of care.

Materials and Methods: We produced a patient passport which was offered to all our copd patients. The document contains information about baseline exercise tolerance, treatment received by the patient at home (i.e. on home nebulisers, home oxygen, home NIV machines). The patients and relatives also decided what outcomes they would prefer in the event of significant clinical deterioration during admission. i.e. itu admissions, cardiopulmonary resuscitation. We also produced an online decision making tool to aid our juniors in delivering non invasive ventilation.

Results: 100 patients participated in the project. All patients were happy with the idea of a personalised care plan, however homeless patients and those who did not speak English stated that they would like the hospital to keep an electronic record. Overall 80 percent of our patients demonstrated increased satisfaction with the quality of care they received. The hospital has set up an online electronic database to improve the patient experience.

Conclusion: Patient's with chronic conditions often have a better understanding and insight into their condition compared to the clinicians treating them. Involving patients in their care plans and the decision making process about clinical care improves patient experience.

Scrub typhus: An emerging mystery in critical care

Moti Lal Bunkar, Rajendra Prasad Takhar, Anil Saxena, Suman Khangaroat, Vinod Jangid, Savita Arya


Government Medical College, Kota, Rajasthan, India.

E-mail: drmotilalbunkar@gmail.com

Aim and Objective: Scrub typhus, a potentially fatal rickettsial infection, is common in India, usually presents with acute febrile illness along-with multi-organ involvement caused by Orientia tsutsugamushi. As there is resurgence in the form of an outbreak of scrub typhus in this part of Rajasthan and there is a paucity of data from this region, an attempt was made to study this entity, to describe the diverse epidemiologic, clinico radiological, laboratory parameters and outcome profile of patients with scrub typhus in a tertiary care center of Hadoti region.

Materials and Methods: All cases of acute febrile illness diagnosed as scrub typhus by positive IgM antibodies against O. tsutsugamushi, over a period of 4 months (July to October 2014) were included in the this descriptive study. All relevant data were recorded and analyzed.

Results: A total of 66 (24 male/42 female) patients were enrolled in the study. Fever was the most common presenting symptom [100%], and in 67% its duration was for 7-14 days. Other symptoms were breathlessness (66.67%), haemoptysis (63.63%), oliguria (51.51%) and altered mental status (39.39%). The pathognomonic features such as eschar (12%) and lymphadenopathy (18%) were not so common. Finding consistent with acute respiratory distress syndrome (ARDS) was commonest radiological observation. Complications noted were respiratory (69.69%), renal (51.50%) and hepatic dysfunction (48.5%). The overall mortality rate was 21.2%.

Conclusion: Scrub typhus has emerged as an important cause of febrile illness and emerging cause of ARDS in this region and can present with varying clinical manifestations with or without eschar. High index of suspicion, early diagnosis and prompt intervention may results in reducing the mortality.

Respiratory ICU balanced scorecard

Deepak Yaduvanshi, Astha Koolwal


Manipal Hospital, Jaipur, Rajasthan, India.

E-mail: lungkare@gmail.com

Aim and Objective: Respiratory ICU Balanced Scorecard : Bench to bedside Development of 18 C -commandments, Quality Indicators in a multi specialty tertiary care hospital.

Materials/Methods: The methodology involved process development of the tool kit against a basic set of parameters bench marked against evidence based guidelines an Indian version of the scaled down is lacking so we involved all stake holders in the development of 18C commandments in a family run traditional hospital being taken over by a corporate chain of hospital. This study comprises in depth analysis of various clinical and non clinical hospital operations from all areas. It has been observed that Lean and six sigma which are complementary quality improvement tools can help to achieve these goals however the application of the same is a long drawn process and the paucity of the trained manpower to implement these from bench to bedside. We at Manipal hospital developed and refined form of parameters called 18C, Commandments to improve the hospital operation activities particularly in respiratory ICU'S.

Results: The study revealed a scaled-down 18C was a better alternative. It resulted in improving access to care, quality of care and an integrated hospital operations. Lean management primary begins with underlying principle of eliminating waste so that all work adds value and serves the customer's needs. Identification and recognition of value-added and non-value-added (waste) steps in every process is the beginning of the journey toward lean operations.

Conclusion: In hospital industry the operational efficiency means rapid access to care, minimum waiting time while at the same time delivering defect free quality care at the minimum cost. In order to undertake service improvement in any dimension it is necessary to use a standard method that enables us to undertake the current process, determine the desired changes and thereby improve it and 18c served as commandments in our journey.

Outcome of NIV in post infective AHRF

Mrityunjaya Singh, Manoj Meena, G. N. Srivastava, J. K. Samaria, Shruti Singh


Institute of Medical Sciences, JLN Medical College, Ajmer, and BHU, Varanasi, Uttar Pradesh, India. E-mail: dr.mrityunjaya@gmail.com

Aim and Objective: To determine the outcome of different Non Invasive Ventilation (NIV) settings in patients of post-infective Acute Hypoxemic Respiratory Failure (AHRF).

Materials and Methods: This was a prospective observational study on patients of acute hypoxemic respiratory failure (based on arterial blood gas analysis) with provisional diagnosis of acute infective etiology admitted during one year period. 49 Previously healthy young patients between 18 to 45 years of age were included 27 and 22 in Group A and B respectively. Patients with co-morbidities like Diabetes mellitus, hypertension, obesity and underlying respiratory diseases were excluded. ABG was analysed at 0, 1, 4 and 12 hours of NIV institutions.. NIV was applied to Group A at ePAP = 4 to 5 cm of H 2 O and iPAP (inspiratory Positive airway pressure) = 12 cm of H2O; Pressure support of 10 cm H 2 O. The iPAP was gradually adjusted to maintain oxygen saturation of >90% with oxygen. Group B was started NIV at e/iPAP of 4/8 (Pressure support = 4) and both ePAP and iPAP were adjusted to maximum of 12 and 24 resppectively. Need for endotracheal intubation/failure of NIV trial was the primary outcome.

Results: Group A showed earlier reduction in respiratory rate and stabilization of blood pressure and heart rate compared to group B. 9 patients in Group A and 11 patients and group B required Endotracheal intubation after mean 5±1.3 and 3.2±1.8 days respectively.

Conclusion: Higher Inspiratory pressure support and lower expiratory positive airway pressure improves outcome of NIV trial in Acute post-infective hypoxemic respiratory failure.

Outcome in mechanical ventilated patients of IRCU

Yogesh Wagh, N. T. Awad, Jairaj Nair


LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India. E-mail: yogeshwagh12345@gmail.com

Aim and Objective: (1) To study outcome of mechanically ventilated patients. (2) Corelation of organ involvement and ventilator, IRCU and hospital stay.

Materials and Methods: 30 Mechanically ventilated patients of intensive respiratory care unit (IRCU) in a tertiary care hospital were followed till discharge.Patients were admited for various causes like Chronic obstructive pulmonary diseases in exacerbation,Post TB obstructive airway diseases, Tetanus, Hanging, Accute febrile illness, Acute respiratory distress syndrome. They were evaluated for number of organs involved on admission based on investigations like Biochemistry and Arterial blood gas analysis. Outcome were calculated based on number of days of hospital stay, days in intensive respiratory care unit and ventilator days.

Results: Those having more than three organ involvement and those with increased respiratory rate on admission, required longer stay on ventilator, IRCU and total hospital days (Statistically significant P.

Conclusion: Greater the organ involvement and greater the respiratory rate, greater is ventilator IRCU and hospital stay.


   Other Specific Lung Disorders Top


Reference values for the SMWT in Obese individuals

Ashwin Songara, Ravi Dosi, Ashok Bajpai, Mriganka M. Misra


SAMC and PGI, Indore, Madhya Pradesh, India. E-mail: ashwin.osr@gmail.com

Aim and Objective: ( 1) Correlation of Anthropometric measures with SMWD. (2) To find the Reference equation to predict the distance walked during SMWT in obese individuals.

Materials and Methods: The study was conducted at SAMC and PGI, with 100 obese individuals (65 Male and 35 Female) with BMI>30kg/m 2 . Baseline vitals and Anthropomertric measures were taken and Six Minute Walk Test (SMWT) was performed according to the ATS guidelines. Obese individuals having any cardiovascular,neurological and Respiratory disease were excluded.

Results: Distance walked during SMWT was significantly correlated (by linear regression method) to age, oxygen saturation and BMI.The proposed Reference equation is: 6 MWT distance = (6.8) Oxygen Saturation-(4.3) BMI-(0.6) Age-170.64 [Evolved from Linear Regression coefficient table and model summary R value] In the multiple regression analysis, age, oxygen saturation and BMI explained 86%of the total variance in 6 MWT. The average difference between predicted and measured 6MWT values didn't reach statistical significance but the correlation was significant.

Conclusion: A Reference equation specific for the obese population was provided; it can be used as realistic benchmark in rhe rehabilitation setting to assess the functional capacity, plan exercise intensity and monitor changes over time.

Predictors of postop pulmonary complications

R. Radhai, K. Anupama Murthy, R. Karthikeyan, Nithilavalli, C. Siddhuraj


PSG Institute of Medical Science and Research, Coimbatore,

Tamil Nadu, India. E-mail: radhai.prasanna@gmail.com

Aim and Objective: To calculate the incidence of post operative pulmonary complications following extrathoracic surgeries done in our institution after pre operative fitness is given by Pulmonologist. To derive predictors of respiratory complications after extrathoracic surgeries which led to increased post operative morbidity and mortality. To utilize this data to develop validated tool for pre operative pulmonary risk stratification.

Materials and Methods: Retrospective data of 100 patients who were evaluated for preoperative fitness was collected from referral register of Respiratory Medicine Department, PSG IMSR. Their post operative period were studied for complications, predictors of clinical and laboratory parameters and ventilator requirement. These predictors were analysed to derive a model to predict adverse post operative pulmonary outcomes.

Results: Among the composite variables studied, 32 (32%) patients had respiratory failure for atleast 24 hours postoperatively (PORF), 9 (9%) required post operative ventilatory support for more than 6 hours (POVS), 19 (19%)had one of the established respiratory complications (PORC) like pleural effusion, atelectasis, pneumonia, ARDS and exacerbation of obstructive lung disease. Prediction model for PORF showed good discriminative properties with ROC analysis showing AUC 0.875 (95% CI 0.799-0.951). Independent predictors of PORF were elderly age, female gender, abnormal ECG, malignancy, abdominal surgery and duration of surgery. Independent predictors of PORC were emergency surgery and blood urea nitrogen. Prediction model for PORC showed fair discriminative properties with ROC analysis showing AUC 0.709 (95%CI 0.527-0.891). Independent predictors of POVS were malignancy and duration of surgery.Prediction model for POVS showed good discriminative properties with ROC analysis showing AUC 0.783 (95%CI 0.589-0.976). Pre operative administration of bronchodiators appeared to prevent PORC independent of age, gender, BMI and baseline respiratory comorbidity (adjusted odds ratio: 0.172 (95%CI 0.035-0.843); p=0.03). Other preoperative interventions did not protect against any of the studied adverse postoperative outcomes.

Conclusion: Our study has found a significant post operative respiratory morbidity burden in patients undergoing extrathoracic surgeries. Pre operative pulmonary risk stratification is essential for the physician to reduce the post operative pulmonary complications. Predictors for the same were derived from the data to assess mortality and morbidity developing due to postoperative adverse respiratory outcomes.

Gender differences in polysomnographic study profile of obstructive sleep apnea patients

Vikas Rajendra Patel, Vikas Rajendra Patel, Dilip Mhaisekar, Vijay Kumar Kapse


Dr. S.C.G.M.C, Nanded, Maharashtra, India.

E-mail: vikaskauraw@gmail.com

Aim and Objective: To study gender differences in polysomnographic profile of patients with obstructive sleep apnea.

Materials and Methods: We studied the influence of gender on the polysomnographic features of obstructive sleep apnea (OSA) in a study of 100 patients with OSA diagnosed by overnight polysomnographic study (PSG) at Polysomnography laboratory at Dr S.C.G.M.C Nanded. The severity of OSA was assessed by apnea- hypopnea index (AHI) for total sleep time (AHItest). Differences in OSA during different stages of sleep was assessed using AHI as:NREM sleep-AHInrem, REM sleep-AHIrem and calculating the "REM difference" -AHIrem− AHInrem. Each polysomnographic study was classified as (1) mild OSA,occuring predominantly during REM sleep (REM- OSA); (2) OSA of any severity, occuring predominantly in the supine position (Sup OSA);(3) OSA without a predominance in a single sleep stage or body position (A OSA). The statistical test (chi square test) was used to test the significance by calculating 'p' value.

Results: (1) The male-to-female ratio was 2.9:1 for all OSA patients, and increased from 1.9:1 for patients with mild OSA to 6:1 for those with severe OSA. (2) The mean AHItest for men was significantly higher than that for women (31.8 versus 20.2; p<0.05). Women had a lower AHInrem than did men (13.1 versus 26.9; p<0.05), but had a similar AHIrem (36.7 versus 35.2).(3) Women had a significantly higher REM difference than did men (27.6 versus 11.1).(4) REM- OSA occurred in 59% of women and 22% of men with OSA (p<0.05). (5) Sup- OSA occurred almost exclusively in men.

Conclusion: (1) OSA is less severe in women because of milder OSA during NREM sleep. (2) Women have a greater clustering of respiratory events during REM sleep than do men. (3) REM OSA is disproportionately more common in women than in men (Role of REM suppressant drugs). (4) Sup OSA is disproportionately more common in men than in women (Role of positional therapy).

A study on tobacco smoking among college students

Mahshan Kalpaka Muhammed, Vishnu Sharma, Alka Bhat


A. J. Institute of Medical Sciences, Mangalore, Karnataka, India. E-mail: mahshaankm@gmail.com

Aim and Objective: To assess and compare the knowledge, attitude and awareness regarding health hazards of tobacco use among students from selected colleges in Mangalore.

Materials and Methods: This is a cross sectional self-administrated questionnaire based study done on students in the colleges within Mangalore city. Total 4000 students, both male and female between age group 18 to 24 years were randomly selected. Questionnaires in printed forms regarding knowledge, attitude and awareness about tobacco use were distributed among the students and answers were collected in written. Data was compiled and represented by means of tables, diagrams and chi-square test.

Results: Out of 4000 study population, 2060 (51.5%) were males and 1940 (48.5%) were female within age group of 18 to 24 years, Mean age 18.902 and standard deviation 1.02. Out of total students, 529 (13.2%) were using tobacco products, of which 471 were males and 58 were females. Mean duration of initiation of smoking was 2.61 years.45.1% of students started smoking to relieve stress while 34% as fun. Cigarette smoking was the commonest form (86%) of tobacco use. 93.6% of smokers were having smokers in the family. Majority (75.4%) were willing to quit.Main reason (58.5%) to quit was to avoid health hazards. While addiction (57.2%) followed by peer pressure (24.3%) made the rest to continue the habit. 90% of study population were aware about the health hazards caused by smoking. Surprisingly, 52% of total college students were unaware of passive smoking and 10.1% thought smoking as beneficial.

Conclusion: Majority of the college students were aware about the health hazards of smoking. More than half of students were unaware about the hazards of passive smoking. Majority were willing to quit smoking. Majority of the smokers had elder members in the family who were smokers, which may have been the strong reason for these youngsters to initiate smoking.

Lung manifestations in chronic and recurrent uveitis

S. R. Jyothi, K. Anitha Kumari, C. Sreekala


Department of Pulmonary Medicine, Medical College, Thiruvananthapuram, Kerala, India. E-mail: drjyothikailash@gmail.com

Aim and Objective: Primary objective To assess the pattern of lung involvement in chronic and recurrent uveitis Secondary objective To study the proportion of sarcoidosis and pulmonary tuberculosis in chronic and recurrent uveitis.

Materials and Methods: A cross sectional study during a period of one year (may 2014 - may 2015), was conducted in patients with chronic and recurrent uveitis in Medical College Thiruvananthapuram, Kerala. All the patients were evaluated clinically, hematologically, biochemically and radiologically as per the standard protocols. An HRCT thorax was taken for all the patients.

Results: 88 patients with chronic and recurrent uveitis referred to us were evaluated for pulmonary pathology. After the evaluatons 38 patients had a definitive pulmonary pathology. 16 patients were diagnosed with Sarcoidosis, out of which 5 were biopsy proven. 11 patients had Pulmonary Tuberculosis among which one was sputum positive case. Pleural thickening was seen in 4 patients and 4 showed healed lesions of old Pulmonary Tuberculosis. 2 patients had findings suggestive of Asthma. 1 patient with non small cell lung cancer - adenocarcinoma pattern with optic nerve head scondaries presented as chronic posterior uveitis without any pulmonary symptoms. Our study showed that there is no significant added advantage for HRCT thorax over a digital chest X-ray (p=0.318). There was a significant elevation in the level of serum ACE in patients diagnosed as Sarcoidosis (83%, p=0.023).

Conclusion: A treatable pulmonary pathology as a cause of uveitis was dectected in 30.6% of patients with chronic and recurrent uveitis. As evidenced from previous studies our study also showed that sarcoidosis is a major cause for chronic and recurrent uveitis. Tuberculosis constitutes the second commonest pulmonary cause. Our study provides convincing evidence regarding the relationship between serum ACE and sarcoidosis. Addition of an HRCT thorax does not provide any added benefit in diagnosis.

Diaphragmatic function in healthy individuals

Mukesh Kumar Sharma, Dhruva Chaudhry


Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. E-mail: drmks80@gmail.com

Aim and Objective: Assessment of diaphragmatic functions in healthy individuals of north India with use of B-mode ultrasonography.

Materials and Methods: A total of 50 individuals and 97 hemi-diaphragms were studied in healthy individuals attending department of pulmonary and critical care medicine PGIMS Rohtak along with patients. People were assessed regarding symptoms, anthropometric data (height, weight and BMI) and habits (smoking and alcohol). After proper training from experienced radiologist, B-mode USG was done to assess the diaphragmatic function in person lying supine and breathing normally (Tidal respiration). The diaphragmatic thickness was measured at end expiration and end inspiration in the zone of apposition of the diaphragm with the lateral rib cage using 7-10 MHz curvilinear probe set to B mode. Diaphragmatic contractility was also calculated for each diaphragm.

Results: Right diaphragm was assessed in all patients (n-50) and left diaphragm was not assessable in 3 patients (n-47). A total of 97 hemi-diaphragms were assessed. Mean age of study population including male and female were 37.29 ±10.49 and 41.67±8.08. Male: Female ratio was 3.1: 1. Mean right End Expiratory diaphragmatic thickness in male and female was 0.54 ±0.07 cm and 0.51 ±0.04 cm respectively and similar end expiratory diaphragmatic thickness was noted on the left side. Mean end inspiratory diaphragmatic thickness was in male and female was 0.80 and 0.82 cm. Mean change in diaphragmatic thickness in right and left side was 50.0%±10.8% and 56.0% ±15.4 % respectively. Various parameters like age, sex, height, BMI alcohol and smoking showed weak co-relation with diaphragmatic thickness and contractility.

Conclusion: Data of diaphragmatic function (thickness and contractility) assessment in healthy Indian individuals is of importance in future studies planned for evaluation of diaphragmatic function in patients suffering from diaphragmatic disorders (i.e. diaphragmatic paralysis) or in intensive care (i.e. weaning). However present study has small number of individuals, studies involving large number of person with true representation of various groups is needed in future.

Tadalafil for group 3 pulmonary hypertension

M. K. Vinu, E. Jyothi, K. P. Suraj, T. P. Rajagopal


Institute of Chest Diseases, GMC, Kozhikode, Kerala, India. E-mail: mkvinu2010@gmail.com

Aim and Objective: To study the effect of Tadalafil in patients with group 3 pulmonary hypertension (PH) and various adverse effects of Tadalafil.

Materials and Methods: The study was conducted from June 2013-March 2015, at Institute of Chest Diseases, Medical College, Kozhikode. Out of 90 diagnosed cases of group 3 PH who met the inclusion criteria, 30 were given Tadalafil and 60 matched patients were kept as controls. A baseline 6 minute walk test (6MWT) was done for all patients. Patients were started on 20mg Tadalafil once daily, monitored for adverse effects, dose increased to 40 mg od if tolerated and response was measured as the change in 6MWD from baseline to week 16, improvement in baseline saturation and any change in saturation fall during 6MWT which was compared with that of controls. Subjects were monitored once in two weeks for compliance, any change from baseline in above parameters and adverse effects for a period of 16 weeks. 4 patients who developed saturation fall on introduction of Tadalafil were excluded from study.

Results: There was statistically significant improvement in 6MWD, improvement in baseline saturation and reduction in saturation fall during 6MWT in patients treated with Tadalafil. The only noticed adverse reaction was severe saturation fall in four patients.

Conclusion: Tadalafil is effective in treating group 3 PH. Large randomised trial is recommended as sample size was small.

Intrapleural instillation of MESNA in empyema

Suprova Chakraborty, Prithvi Chandra, S. K. Kirolikar, C. S. Ghosh, T. Dash, S. Trivedi


J.L.N Hospital, Sec-9, Bhilai, Chhattisgarh, India.

E-mail: dimlight2001@gmail.com

Aim and Objective: To determine the efficacy of mucolytic agent MESNA in dissolving the fibrinous layers in empyema thoracis and thus allowing lung to expand.

Materials and Methods: Selection criteia: Cases who have-radiological evidence of pleural thickening and trapped lung,went under appropriate anti-microbial therapy,where pleural pus was negative for AFB and culture was sterile for pyogenic organisms,where surgical intervention was contemplated. Duration of study-2 yrs, Selected cases-7 (male 6,female1),age:40-60 Procedure:All cases had tube thoracostomy with under water sealed drainage, 1 ampoule of MESNA (600mg) dissolved in 20 ml Normal Saline injected into pleural cavity through intercostal tube and clamped for 2 hours. Patients were asked to change postures frequently and perform blowing exercises.Fluid drained after clampremoval.4 such procedures carried out per day for 7 to 10 days depending upon response.Patients were followed up for 15 to 30 days sine the first instillation

Results: Out of 7 cases,3 showed remarkable response with complete lung expansion and noo further discharge,1 patient lost to follow up and 3 cases showed no response so referred to surgeons.

Conclusion: This small study highlights the efficacy of cheap,innocuous substance like MESNA in chronic empyema assurgery was averted in 3 cases.We recommend a large scale clinical trial to confirm safety and efficacy of MESNA in chronic empyema thoracis.

Role of nicotine dependence in COPD, anxiety and depression

V. Arun Kumar, Rajesh Raman, P. A. Mahesh, B. Jayaraj, Sudharani P. Naik


JSS Medical College, Mysore, Karnataka, India. E-mail: arunkumar.vinayak@gmail.com

Aim and Objective: Primary: To study the correlation between Nicotine Dependence and severity of COPD. Secondary: To study the correlation between severity of anxiety, depression and severity of COPD.

Materials and Methods: A hundred smokers diagnosed with COPD according to GOLD guidelines at JSS Hospital, Mysore were recruited. The scales applied were ST GEORGE'S RESPIRATORY QUESTIONNAIRE, COPD Assessment test (CAT),HAM-A, HAM-D, Fagerstrom Test for Nicotine Dependence and Nicotine dependence syndrome Scale.

Results: The increase in severity of COPD (FEV1 as a continuous variable) was significantly associated with Fagerstrom test score score (r=0.385, p<0.0001). Fagerstrom test score was also significantly associated with Quality of Life measures in COPD, the St George's questionnaire; total St George scores (r=0.41, p<0.0001), impact component (r=0.41, p<0.0001), activity component (r=0.39, p<0.0001), symptom component (r=0.41, p<0.0001). Fagerstrom test score is significantly correlated with COPD assessment Test (CAT), r=0.3, p=0.02. Most of the associations were only mild to moderate. Fagerstrom questionnaire was better than the NDSS scores and the overall NDSS score was significantly correlated only with impact component and total St George scoring system (r=0.22, p=0.028, r=0.21, p=0.04).

There was increasing HAM D score from mild COPD to severe COPD based on GOLD guidelines from 4.86±2.41 to 15.43±8.30 levels. This trend was statistically significant. The mean HAM A scores significantly increased from mild COPD to severe COPD based on GOLD guidelines from 8.71±4.95 to 18.64±7.31. This trend was significant.

Conclusion: Fagerstrom test score assessing nicotine dependence, is significantly associated with multiple phenotypic variables such as FEV1, different quality of life measures and CAT score, implying that higher dependency is associated with increasing severity of COPD. Fagerstrom score was better than NDSS score. Depression and anxiety are significant in patients with COPD and severity of depression and anxiety increases with increasing severity of COPD.


   Tuberculosis Top


Tuberculosis in renal transplant recipients

Arun chowdary Kotaru, Puneet Saxena, S. Narayanan, C. D. S. Katoch, T. Ajai Kumar, Vasu Vardhan


Armed Forces Medical College, Military Hospital, Namkum, Military Hospital (Cardio Thoracic Centre), Ranchi, Jharkhand, India. E-mail: arun.kotaru@gmail.com

Aim and Objective: Tuberculosis is one of the common opportunistic infection identified in renal transplant people due to their immunocompromised status. The objective of the present study was to report the clinical profile and treatment outcome of tuberculosis in renal transplant recipients in a tertiary care hospital.

Materials and Methods: We evaluated all the subjects referred from peripheral hospitals with post renal transplant TB from January 2011 to December 2014. A definite TB case was defined by a positive culture; probable TB by a positive smear microbiology or histologically or clinically; and disseminated TB when two or more organs are involved. Outcomes were classified according to latest WHO guidelines.

Results: Among the 15 subjects of post transplant recipients with tuberculosis evaluated during the study period (male/female: 13/2), 04 patients were diabetic, 03 were hypertensive and 02 had both. 10 patients were diagnosed to have pulmonary, one had extrapulmonary and 03 patients had disseminated tuberculosis. More than half the subjects (8/15) presented as pyrexia of unknown origin (PUO). 4 out of 15 patients were found to be resistant (Single drug resistance-01, MDR-01, XDR-02). 09 patients were cured, 03 patients were under follow up and 03 patients died despite our best endeavours.

Conclusion: Management of Tuberculosis (TB) in renal transplant recipients(RTR) is complex, due to the interactions between immunesupressants and antitubercular drugs. Formulating an appropriate regimen and monitoring drug levels is a challenging task especially in drug resistant tuberculosis and is vital in management. Very limited data is available in the literature. Due to high risk of drug resistance in these subset of people, focus on early detection of resistance and regular follow up of these patients is required.

Drug resistant TB: loopholes and suggestions

Neeraj Gupta, Amit Sharma, K. C. Agarwal, Mukesh Goyal, Piyush Arora, Sabarigirivasan Harish


JLN Medical College, Ajmer, Rajasthan, India.

E-mail: drneerajajmer@yahoo.com

Aim and Objective: The present study was carried out at PMDT site, Ajmer to evaluate the (1) Possible factors resulting in delay in management of Drug Resistant Tuberculosis, (2) To evaluate contribution of Medical College in Diagnosis and (3) To formulate possible suggestions to strengthen the loopholes identified.

Materials and Methods: 77 consecutive MDR suspects attending OPD/ PMDT site were evaluated for (1) Interval between Smear positivity and Deposition of Sputum for LPA, (2) Interval between Sputum deposition and Result Upload, (3) Interval between Sputum Deposition and Report Received, (4) Interval between Reports Received and Admission, (5) Role of Medical College in diagnosis of MDR TB, (6) Treatment offered in the above interval. Results: 1) 59/71 (83%) were able to deposit their sputum within 7 days of smear positivity. 2) 30/32 (94%) of LPA reports were uploaded at IRL site within 7 days. 3) Only 7/66 (10.6%) and 13/66 (20%) patients received their reports within 1 & 2 weeks respectively. 27/66 (41%) were yet to receive reports even after 28 days, probably because of delay in Solid Culture. 4) 21/23 (91%) patients got admitted at PMDT site within 7 days. 5) Reports of 22/41 (54%) patients were procured by Medical College at PMDT site. 6) 47/69 (69%) patients received ATT during delay in the report while 6 patients (8.5%) expired during the period.

Conclusion: 1) There is a significant delay between sputum deposition and receipt of LPA/Culture reports by patient resulting in delayed start of treatment. 2) CB NAAT probably may be Gold Standard for LPA Negative patients than to opt for solid culture. 3) Medical college is more prompt in identifying Drug Resistant TB than other RNTCP staff.

Smear/biopsy versuss gene xpert in diagnosing TB

Renjitha Subhash, Prerna Gupta, K. A. Ameer, M. Joshi, V. Kesavan Nair, P. Arjun


Kerala Institute of Medical Sciences, Trivandrum, Kerala, India. E-mail: renjitha.subhash@yahoo.co.in

Aim and Objective: 1.To compare smear microscopy and/or histopathology with Gene Xpert in diagnosing tuberculosis. 2.To detect rifampicin resistance using Gene Xpert.

Materials and Methods: This is a retrospective, observational study, conducted from April 2015 to August 2015, in which, a total of 153 clinical samples recovered from 141 patients, clinically suspected of tuberculosis, were collected and subjected to smear microscopy or biopsy and Gene Xpert. These included 80 respiratory samples (3 gastric aspirate samples, 5 endotracheal secretion samples, 15 bronchoalveolar lavage samples, 57 sputum samples) and 73 non respiratory samples ( 5 lymph node samples, 6 cerebrospinal fluid samples, 16 pleural fluid samples, 11 tissue samples, 25 ascitic fluid samples, 8 urine samples and 2 pericardial fluid samples).

Results: In 23 out of the 153 samples, Mycobacterium tuberculosis was detected, by Gene Xpert. No rifampicin resistance was detected in any of these samples. Out of the 23, 17 were respiratory samples ( 14 sputum samples, 1 bronchoalveolar lavage sample, 1 endotracheal secretion sample and 1 gastric aspirate sample) and the remaining were non respiratory (2 lymph node samples, 1 pleural fluid sample, 1 urine sample, 2 tissue samples). The non respiratory samples were positive on smear examination also. Out of the 14 sputum samples, which were Gene Xpert positive, 2 were smear negative for AFB. 1 endotracheal aspirate sample which was Gene Xpert positive, was smear negative for AFB. Of all the samples positive by smear microscopy, 3 turned out to be Gene Xpert negative.

Conclusion: 1. Gene Xpert was helpful in detecting 3 more cases of Tuberculosis, which would have been missed, if smear microscopy alone were used. ( 11.5 % cases diagnosed extra) 2. No rifampicin resistance was detected in any of the samples. 3. 3 samples which were positive by smear examination turned out to be Gene Xpert negative.

Diagnosis and mimics of smear negative pulmonary TB

Sonali Parida, Jineesh Joseph, Swapnendu Misra, Ritabrata Mitra, Surajit Chatterjee, Somenath Kundu


I.P.G.M.E. and R and S.S.K.M Hospital, Kolkata, West Bengal, India. E-mail: sonaliparida25@gmail.com

Aim and Objective: Smear negative Pulmonary Tuberculosis is always a clinician's dilemma. The purpose of this study is to assess the role of following tests to differentiate smear negative PTB from other conditions : Induced sputum. Gastric lavage. Fibro optic bronchoscopy, BAL, biopsy, brush, post bronchoscopy sputum. CT guided FNAC from lung lesions. Newer molecular methods like GeneXpert test. Evidence from extrapulmonary sites.

Materials and Methods: The study was conducted on 120 suspected smear negative PTB cases attending Pulmonary Medicine Department of S.S.K.M Hospital and I.P.G.M.E. and R. Appropriate samples were subjected to AFB staining, Culture for M.tb as well GeneXpert tests wherever feasible. FNAC/biopsy from peripheral lymph nodes and skeletal lesions, pleural biopsy, CSF study, brain and abdomen imaging were done in relevant cases. Histopathological evidence in thoracotomy cases were also included.

Results: Out of the 120 smear negative patients 84 were diagnosed to be PTB, 25 cases as malignancy, 10 patients had non -TB pulmonary infections and results were inconclusive in one patient. 73 cases were bacteriologically confirmed as Tuberculosis. Rest 11 cases were diagnosed on the basis of clinco-radiological and/or cytology or histopathological evidence of TB. Yield was highest for bronchoscopy- 78.94%(30/38). Yield from other tests were sputum induction - 14.3%, gastric lavage -77.7%, sputum geneXpert- 71.4%, CT guided FNAC- 63.8%, peripheral lymph node FNAC/biopsy - 62.5% and thoracotomy 75%.

Conclusion: Bronchoscopy can provide excellent material for diagnosis of smear negative pulmonary tuberculosis. Lung carcinoma is a very common TB mimic. Bacteriological confirmation is very important in the diagnosis of smear negative PTB as it helps to establish the diagnosis with certainty and prevents irrational use of anti tubercular drugs.

Menstrual disturbances in pulmonary tuberculosis

Neha Agrawal, Tariq Mahmood, A. D. Shukla, Alok Chandra, Surya Kant, Amrita Chaurasia


Moti Lal Nehru Medical College, Allahabad, King George Medical University, Lucknow, Uttar Pradesh, India. E-mail: agneha04@gmail.com

Aim and Objective: 1. To determine menstrual disturbances in pulmonary tuberculosis patients. 2. To make out the association of menstrual disturbances with bacillary load and severity of disease. 3. To make out associated hormonal correlation.

Materials and Methods: A prospective observational study on seventy female patients of sputum positive pulmonary tuberculosis, aged between 18-40 years, excluding patients of genital tuberculosis and patients with history of previous menstrual disturbances was conducted. A detailed clinical history along with menstrual history was taken and hormonal tests for S.FSH, S.LH, S.Prolactin and S.Estradiol (E2) were done on day 2 or day 3 of menstruation. Data was analysed using appropriate statistical methods.

Results: 1. Oligomenorrhoea was the commonest menstrual disturbance (54.29%) observed, followed by hypomenorrhoea (34.29%). 2. Menstrual disturbances increased as the bacillary load and severity of disease increased (more in multi drug resistant tuberculosis) but no statistically significant correlation was found between them when individual menstrual disturbance was compared. 3. Menstrual disturbances are fairly common and were present in 75.71% of total patients but associated hormonal imbalance were present in 51.43%. 4. Menstrual disturbances of patients without hormonal imbalance (24.29%) reversed early with the treatment of disease.

Conclusion: 1. Menstrual disturbances are fairly common in non genital tuberculosis. 2. Menstrual disturbances were more common in patients who had high bacillary load, drug resistant tuberculosis and longer duration of disease, so early diagnosis and treatment are important so as to reduce the associated menstrual disturbances and associated long term complications like infertility in patients of pulmonary tuberculosis.

King's evil and Pott's curvature-current situation

N. Muthulakshmi, N. Murugan, V. Sundar, A. Mahilmaran, O. R. Krishnarajasekar, D. Ranganathan


Institute of Thoracic Medicine, MMC, Chennai, Tamil Nadu, India. E-mail: dr.lakshmi.naveen@gmail.com

Aim and Objective: 1. To study the clinical data and histopathological and microbiological correlates in clinical suspects of lymph node and spine tuberculosis. 2. To study the pattern of drug resistance in microbiologically confirmed cases of lymph node and spine tuberculosis.

Materials and Methods: 114 patients with clinical suspicion of lymph node (83) and spine (31) in whom treating doctor (pulmonologist, general surgeon, orthopedician) has suggested histopathological/ microbiological diagnosis were enrolled in the study. The clinical history regarding present and past history of anti-tubercular treatment (ATT) and comorbidities were taken. Excision biopsy specimens were obtained after informed consent and were processed for AFB smear examination by Ziehl Neelson method, AFB solid culture in LJ medium, drug susceptibility testing (DST) by 1% proportion method and histopathological examination.

Results: We observed that in 91/114 (79%) of clinical suspects of lymph node (n=67)and spine tuberculosis (n=24) there is histopathological evidence of granulomas. We found 26/114 (22%) of cases to be culture positive[lymph node - 19/83 (22.8%), spine -7/31 (22.5%)] and identified as Mycobacterium tuberculosis. Of the culture isolates 23%(n=6) showed nongranulomatous histology, of these patients 60%(n=4) are HIV reactive and 40%(n=2) diabetic. We observed that 8/26 (30.77%) cases to be resistant to atleast one of first line anti-tuberculous drugs, of which multi drug resistance (MDR) is 15.3%(4/26). We found a multidrug resistance of 15.7%(new-7%, previously treated-40%)in lymph node and 14.2%(new-0%,previously treated-25%) in spine tuberculosis. The resistance rate is 3.19% in new cases and 25% in previously treated cases. The resistance rate in HIV positive patients is 33.3% and HIV negative patients is 29.4%.

Conclusion: In our study we observed the culture yield to be low due to paucibacillary nature of the disease in concordance with earlier studies. In immune compromised state like HIV and diabetes nongranulomatous histology in lymph node and spine TB were noted. We observed MDR TB is nearly 8 times more common in previously treated patients compared to new patients, hence the need for DST in previously treated patients.

Outcome of TB pleural effusion after treatment

Parvathi Rajendran, Davis Paul, Thomas George, C. S. Ajithkumar, C. P. Muraly, O. K. Mani


Government Medical College, Thrissur, Kerala, India. E-mail : parvathi_rajendran@hotmail.com

Aim and Objective: In India, Tuberculosis is the most common cause of exudative pleural effusions in absence of demonstrable pulmonary disease. The available treatment guidelines (including RNTCP) doesn't clearly outline the time for radiological clearance, outcome of treatment and residual pleural lesions. Hence the aim is to study the clinico-radiological outcome of tuberculous effusion Objective: To study the clinical and radiological outcome in patients with pleural effusion started on CAT 1 ATT and to find predictors for prognosis of the disease.

Materials and Methods: A Prospective observational study was conducted on patients with pleural effusion started on CAT 1 ATT under RNTCP in Government Medical College, Thrissur from January 1st 2015 to March 31st 2015. They were under follow up for 6 months.

Results: In 30 patients studied cure rate is 83.3% (n=25). Mean age is 44. 70% (n=21) are males. Mean duration of symptoms is 2 weeks to 1 month (40%; n=12). Loss of appetite and loss of weight are seen in 100% (n=30). 73 % of patients had moderate effusion. Mean ESR is 59.36. Mean ADA is 58.53. ADA is less than 40 in 13.3 % (n=4). Mantoux was positive in 13.3% (n=4). On starting ATT appetite gain is the first symptom of improvement (36.7 % in less than 2 weeks). Complete radiological clearance is seen in 20%(n=6) at 2 months and in 83.3%(n=25) after starting ATT. Residual pleural thickening is noted in 60% (n=18). Duration for radiological clearance of effusion is predicted by elevated ESR (p=0.014), ADA (p=0.026), and faster reversal of symptoms (p=0.001). High ESR (p=.002), ADA (p=0.001) act as predictors for pleural thickening. There's no statistically significant relation duration of symptoms (p= 0.194) and to rate of radiological clearance of effusion (p=0.072).

Conclusion: Cure rate of pleural effusion treated with CAT 1 ATT is 83.3%. Residual pleural thickening is seen in 60% of patients. ESR,ADA and duration for symptom reversal are important predictors of outcome.

Is catII regimen effective in inh resistant TB?

M. J. Qureshi, N. K. Jain, A. Singh, S. P. Agnihotri, N. Joshi


IRD, SMS Medical College, Jaipur, Rajasthan, India. E-mail: rahiqureshi86@gmail.com

Aim and Objective: To assess outcome of patients with INH resistant tuberculosis put on RNTCP retreatment regimen (CatII).

Materials and Methods: All retreatment cases were put on retreatment regimen (cat II regimen) after sending sputum for mycobacterial culture & drug sensitivity test (DST). Diagnosis of INH resistant pulmonary tuberculosis was established based on sputum mycobacterium culture and drug susceptibility test report and these patients were followed up and assessed according RNTCP protocol into treatment completion, cure, default, failure, death & transfer out.

Results: Out of 234 retreatment (CatII) patient subjected to mycobacterial culture and sensitivity, 37 (15.82%) patients had INH resistance. Among these INH resistance patients, 18 (48.6%) patients cured, 11 (29.9%) patients failed, 6 (16.2%) patients died and 2 (5.4%) patients defaulted. Among 11 (29.9%) failure patients, 6 (54.55%) patients acquired additional rifampicine resistance and became MDR TB.

Conclusion: The results of this prospective study on INH drug resistance tuberculosis patients provide evidence that the standard retreatment approach for treatment of INH drug resistant tuberculosis in RNTCP is not adequate as it results in poor outcome with high death rates and high rates of treatment failure with amplification of drug resistance and acquisition of MDR-TB.

Effect of antibiotic on sputum status of PTB cases

K. Venugopal, P.R. Sreelatha, Suresh Raghavan


General Hospital, Medical College, Alappuzha, Kerala, India. E-mail: dtovenu@yahoo.com

Aim and Objective: RNTCP is being implemented all over India since 1997. Prioritization of treatment is based on sputum status. There are so many antibiotic in common use having action on micobacteria. So it is relevant to study any effect of antibiotic on sputum status of pulmonary tuberculosis cases. Aim of the Study: To evaluate effect of commonly used antibiotic on sputum status of newly diagnosed pulmonary tuberculosis cases registered under RNTCP.

Materials and Methods: All the pulmonary tuberculosis patients registered in Alappuzha TU are included in the study in IInd Quarter 2012. A detailed history of antibiotics received in the last three months was taken.

Results: Of the 68 patients with sputum positive result, 49 (72%) gives the history of antibiotic usage with following divisions 17 - Quinolenes (34.69%), 19 - Beta Lactamase (38.78%), 3 - Macrolides (6.12%) and 1 - Cloxacillin (2.04%). Of the 64 sputum negative cases, 55 (85.94%) gives antibiotic history, of which 19 - Quinolenes (35.55%), 15 - Beta Lactamase (27.27%), 8 - Macrolides (14.55%) and 5 - Cloxacillin (9.09%). There is apparent influence on sputum status by prior antibiotic under field conditions (72% vs 85.94%). Statistical significance seem only with Cloxacillin with P value < 0.05.

Conclusion: Antibiotic having action on micobacteria may have an effect on sputum status of pulmonary tuberculosis cases. More study in these regard is necessary.


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Impulse oscillometry in the diagnosis of asthma

S. Jebin Roger, T. Balamugesh, D. J. Christopher, R. Manjula


Christian Medical College, Vellore, Tamil Nadu, India. E-mail: jebinroger@hotmail.com

Aim and Objective: The primary objective was to find out a reference value for significant reversibility of R5 after bronchodilator by impulse oscillometry (IOS) with spirometry as the gold standard and the secondary objective was to grade severity of airflow limitation with IOS by correlating with FEV1 in patients with asthma.

Materials and Methods: We included a total of 636 patients with a clinical diagnosis of asthma and 177 healthy individuals into the study. All patients and healthy individuals performed IOS and spirometry both before and after bronchodilator. Statistical analysis was performed using Spearman's correlation coefficients between R5 and FEV1. ROC analysis was done between cases and controls with R5 to find out the sensitivity, specificity, AUC and cutoff value at the best sensitivity and specificity for significant reversibility, airflow limitation and severe airflow limitation as compared with FEV1.

Results: R5% and FEV1% bronchodilator reversibility showed a moderate and significant correlation with a correlation coefficient of -0.334 (p < 0.001). The ROC analysis showed a cutoff value of -20.75% at the best sensitivity and specificity of R5% bronchodilator reversibility. A linear regression prediction model between R5% and FEV1 showed that a 1% increase in FEV1% would be equal to a 2.6% decrease in R5%. Pre bronchodilator FEV1% with R5% showed a strong and significant correlation with a correlation coefficient of -0.588 (p < 0.01). ROC analysis for pre bronchodilator R5% predicted showed a cutoff value of 180.8% to diagnose airflow limitation. ROC analysis for pre bronchodilator R5% predicted to diagnose severe airflow limitation found a cutoff value of 230.15% for pre bronchodilator R5% in patients with asthma.

Conclusion: We suggest that a value of more than 20% change in R5% post bronchodilator may be considered significant reversibility, a value of more than 180% for pre bronchodilator R5% predicted to diagnose airflow limitation and more than 230% for pre bronchodilator R5% predicted to diagnose severe airflow limitation in adult Indian patients with asthma.

Impact of Indian equations on spirometry

Manu Madan, Sunil K. Chhabra


Vallabhbhai Patel Chest Institute, New Delhi, India. E-mail: manu.madan100@gmail.com

Aim and Objective: Use of Caucasian equations for interpretation of spirometry data is a common practice in Indian laboratories. We have recently published prediction equations for Indian population using the 2005 ATS-ERS guidelines for spirometry. Use of inappropriate equations results in errors in interpretation. We carried out a study to examine the concordance between Caucasian and Indian equations in interpretation of spirometry.

Materials and Methods: Data of 1945 consecutive spirometry tests carried over six months was analysed. The US Caucasians prediction equations and Indian equations developed by us were were used. Values below the lower limits of normal were considered abnormal. Following the 2005 ATS-ERS algorithm, patients were categorized into four patterns: Normal, Obstructive, Restrictive, Mixed. The proportions of patients in these groups by the two equations were compared and agreement between these was evaluated.

Results: The age range was 18 to 90 years, mean (sd) of 45.45 (15.3). 1057 (54.3%) patients were males. FVC, FEV1 and FEV1/FVC ratio were reduced in 1034 (53.0%), 1290 (66.2%) and 831 (42.6%) patients, respectively, by the Caucasian equations, and in 557 (28.6%), 698 (35.8%) and 698 (35.8%) patients, respectively, by the Indian equations. With Caucasian equations, the distribution of patients was: Normal, 587 (30.2%); Obstructive, 378 (19.4%); Restrictive, 527 (27.1%) and Mixed, 453 (23.3%) whereas it was 947 (48.7%), 441 (22.7%), 300 (15.4%) and 257 (13.2%), respectively, with Indian equations (p).

Conclusion: Use of Caucasian equations to interpret spiromatry data of Indian patients results in substantial misclassification. These equations overdiagnose abnormality with restrictive and mixed patterns. This would lead to errors in management. Hence, Indian equations should be used to interpret spirometry data of Indian patients.

Exercise desaturation in screening IP in PSS

P. V. Harsha, Davis Paul, Thomas George, C. S. Ajith Kumar, C. P. Muraly, O. K. Mani


Government Medical College, Thrissur, Kerala, India. E-mail : harshapv8@yahoo.com

Aim and Objective: Background Interstitial Pneumonitis is common in patients with progressive systemic sclerosis (PSS). Exercise desaturation testing is a simple test to identify gas exchange abnormality in IPF. Exercise desaturation is a classic finding in IPF,but whether it is a valuable tool in screening Interstitial Pneumonitis in systemic sclerosis is yet to be studied. Aim To find out whether exercise desaturation is helpful, in screening Interstitial Pneumonitis in patients with PSS.

Materials and Methods: This is a cross sectional study conducted in the Department of Pulmonary Medicine and Rheumatology clinic,Govt.Medical College,Thrissur among patients having PSS during the period, january 2014 to december 2014.

Results: Total number of patients was 30.Number of patients having respiratory symptoms were 27 (90%).CXR was abnormal in 20 patients (66.6%).HRCT was abnormal in 28 (93%) patients out of which 22 (73%) patients had Interstitial Pneumonitis (p 0.03).UIP was the significant pattern, found in 43% (n13) (p 0.01), NSIP 20% (n 6) and mosaic pattern 10%(n 3). Mean FVC was 66.7% (16.41SD).Mean 6MWD was 395.3m (107SD).Resting oxygen saturation > 90% in 28 patients. Post exercise desaturation was found only in 4 patients (13.3%) all of them with an UIP pattern and 2 of them died during the study period.

Conclusion: Exercise desaturation is not a significant feature in PSS like that in IPF hence may not help in screening Interstitial Pneumonitis.

Pulmonary sequale in treated swine flu patients

V. K. Sabarigiri Vasan Harish, Piyush Arora, Neeraj Gupta, Ramakant Dixit, Ankur Gupta, Arjun Chandran


JLN Medical College, Ajmer, Rajasthan, India. E-mail: sabarigirivasan103@gmail.com

Aim and Objective: To assess the pulmonary sequale in patients who recovered after swine flu treatment without underlying previous respiratory disease.

Materials and Methods: This is a 6-12months case series conducted in 25 treated swine flu symptomatic patients who attended OPD of Department of Chest. They were assessed clinically, radiologically and by other relevant investigations including PFT. With these parameters we assessed the long term sequale after swine flu infection.

Results: Out of 25 patients, Female: male ratio was 2:1. The mean age was 40 yrs. The commonest presenting symptom reported were dry cough (72%), breathlessness (60%), chest tightness (28%) and chest pain (20%). Spirometry revealed restrictive pattern in 8 patients (32%), obstructive pattern in 3 patients (12%),and mixed pattern in 2 patients (8%). DLCO was done in patients with restrictive pattern (8 patients), 3 had mild reduction, 2 had moderate reduction, 3 had normal diffusion. Most common HRCT pattern was predominant GGO noted in 6 patients, 2 patients showed ILD pattern (1 NSIP and 1 UIP), 3 patients showed consolidation on HRCT and 3 patients showed only centrilobular nodules, while mixed pattern including GGO, nodules, consolidation seen in 4 patients and 7 patients had normal HRCT pattern

Conclusion: Pulmonary sequale are not uncommon after swine flu infection,but studies and literatures are lacking. In our case series of 25 patients who had no prior history of any respiratory disease, were still symptomatic 6-12months after being treated for swine flu. Out of 25 patients, 13 (52%) patients had abnormal lung function on spirometry and 18 (72%) patients had abnormal HRCT pattern revealing sequale of swine flu illness in lungs. So this study shows the importance of the follow up with proper workup of all symptomatic swine flu patients after treatment.

Clinico-radio-spirometric evaluation in COPD

Rajdeep Dhandhukiya, Gaurav Shahu, Amit R. Dedun, Rajesh N. Solanki


B.J. Medical College, Ahmedabad, Gujarat, India. E-mail : rajdeep.dhandhukiya@gmail.com

Aim and Objective: 1.To study the clinical, radiological and spirometric profiles in patients having chronic obstructive pulmonary disease 2. To determine the etiological factors of chronic obstructive pulmonary disease. 3. To study correlation between clinical, radiological and spirometric profiles in cases of chronic obstructive pulmonary disease.

Materials and Methods: The present study was carried out at Department of Pulmonary Medicine, Civil Hospital Ahmedabad, in 50 patients of COPD admitted in Hospital during period of nov 2010 to nov 2012.

Results: In present study COPD predominantly seen among males 66% and females were 34%. Peak prevalence was seen age group of 50-59years. Tobacco smoking was commonest (74%) factor, biomass exposure (12%)& occupational exposure (6%). Clinical symptoms were dyspnea (100%), cough with/without expectoration (88%), chest tightness (30%), fever (30%) weight loss (28%) Grade-5 dyspnoea significantly associated with very severe airflow obstruction and radiological changes. HRCTscan thorax has sensitivity of 75% with positive findings of air trapping (45%) emphysema (30%), bronchial wall thickening (30%) bronchial dilatation (12.5%). Presence of hypoxia is common with very severe airflow obstruction. According to spirometric study for obstruction, there were (34%) very severe, (44%) severe, (22%) moderate airflow obstruction.

Conclusion: Though, COPD traditionally is associated with cigarette smoking. Non-smoking causes of COPD are becoming increasingly common. Exposure to biomass fuel such as chullah smoke/kerosene smoke, are more common in females. Occupational exposure, exposure to high levels of outdoor air pollution is going to be responsible for a large population of COPD in the future. A clinical, spirometric & radiological correlation will aid a better guidance to treatment & alleviation of causal factors.

Cardio-vascular status and morbidity in COPD

Sapan Kumar


Christian Medical College, Vellore, Tamil Nadu, India. E-mail: jupitersap@gmail.com

Aim and Objective: To assess cardiovascular comorbidities in COPD patients. To study the echocardiographic function in patients with COPD. To correlate lung function abnormality with cardiovascular abnormality.

Materials and Methods: A Cross sectional observational study for a period of 1 year from 1st july 2014 to 30th july 2015. Patients were recruited from outpatient department of Pulmonary Medicine, CMC Vellore. A total of 122 COPD patients who fulfill the study criteria were recruited by random sampling. A detailed medical history along with physical examination was done. Patient's cardiac and respiratory functions were assessed by appropriate blood tests, ECG, ECHO and PFT.

Results: Of 122 COPD patients - 8.2% had mild, 48.3% had moderate, 29.5% had severe and 13.9% had very severe grade of COPD (GOLD criterion The most prevalent cardiovascular co-morbidity was hypertension 40.2%followed by coronary artery disease 20%, previous MI 7.4% and cerebrovascular accident 4%. Prevalence of PAH as determined by transthoracic ECHO was 61% with 59.2%, 27.6% and 13.1% being mild, moderate and severe respectively. Increasing trend of PH was observed from 50.8% in mild, 77.7% moderate, 88.2% in very severe COPD, of these cor pulmonale was observed in 23%- 10% in moderate, 22.2% in severe and 53 % in very severe COPD. LV and RV systolic dysfunction observed in 14% of the patients. LV diastolic Dysfunction was observed in 65.57% patient.

Conclusion: Current study shows a significant association between cardiac co-morbidities and COPD in indian subjects. Also a significant co-relation between severity of COPD with corpulmonale. There is a case for regular cardiovascular screening in all COPD patients for early identification, monitoring and early treatment patients, since they are likely to suffer increase risk of cardiovascular event.

Aeroallergen sensitisation in AR with/without CRS

Shekhar Kunal, Ashok Shah


Vallabhbhai Patel Chest Institute, New Delhi, India. E-mail: kunalrocks89@gmail.com

Aim and Objective: To determine the pattern of skin prick test (SPT) reactivity to common aeroallergens among patients with allergic rhinitis (AR) with/without associated chronic rhinosinusitis (CRS).

Materials and Methods: The study comprised 78 consecutive patients with AR (males/females, 42/36), between 18 to 60 years, enrolled from outpatients department of VP Chest Institute, University of Delhi. IRB approval and informed consent was taken. AR was diagnosed according to ARIA guidelines. All patients had positive SPT and normal spirometry. CT-PNS, done in all patients, assessed the presence of CRS. CRS was diagnosed as per EPOS. Patients were divided into two groups: AR (Group 1) and AR with CRS (Group 2). SPT was done with 66 different types of aeroallergens along with positive and negative controls.

Results: The patients were categorised as follows: Group1 with 32 (41%) and Group2 with 46 (59%) patients. 43/78 (55%) patients were sensitised to indoor allergens only, 19/78 (24%) to outdoor allergens only and 16/78 (21%) to both. The prevalence of sensitisation in decreasing order: female cockroach 38/78 (49%), housedust mite 28/78 (36%), housefly 27/78 (35%), cynodon 14/78 (18%) and cenchrus 9/78 (11%). In Group1, 21/32 (66%) patients were sensitised to indoor allergens only as compared to 22/46 (48%) in Group2 without significant difference (P=0.12). The proportion of patients sensitised to outdoor allergens only was significantly higher in Group2 (15/46 {33%}) as compared to Group1 (4/32 {13%}) (P=0.04). 7/32 (21%) patients in Group 1 while 9/46 (19%) patients in Group2 were sensitised to both indoor and outdoor allergens without significant difference (P=0.80).

Conclusion: A high prevalence of sensitisation to indoor aeroallergens was seen in patients with AR with/without associated CRS. Patients with AR (Group1) had greater sensitisation to indoor allergens as compared to patients with AR and associated CRS (Group2). However, the difference was not significant. Similarly, patients with AR and associated CRS (Group2) had significantly higher sensitisation to outdoor allergens as compared to patients with AR alone (Group 1).

Pulmonary rehabilitation and N-acetyl cysteine in COPD

Gaurav Bhati, Kshitij Agarwal, Vishal Bansal, S. N. Gaur


Departments of Pulmonary Medicine and 1 Physiology, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India. E-mail: dr.gauravbhati@gmail.com

Aims and Objectives: To assess the impact of N-acetyl cysteine and pulmonary rehabilitation on quality of life in patients with COPD.

Methods: Sixty-four subjects with moderate to severe COPD as per GOLD 2010 guidelines, attending the OPD at our Institute were randomly allocated into 2 groups of 32 patients each. Group A underwent pulmonary rehabilitation while Group B received N-acetylcysteine (NAC) 600 mg twice daily, both for 8 weeks. Quality of life (QoL) was assessed through Saint George's Respiratory Questionnaire (SGRQ), COPD assessment test (CAT); and 6 Minute Walk Distance (6MWD); sputum quantity and purulence, along with number of hospital admissions were documented before and after the study. Intra-group and inter-group comparisons were made for the parameters in both the groups.

Results: In Group A, SGRQ decreased from 61.18±6.44 to 44.85 ±11.41 (p <0.001), CAT score decreased from 20.13±2.32 to 15.72±3.05 (p <0.001), 6MWD increased from 358.14±40.18m to 384.51±40.18m (p<0.001) while sputum amount mean rank decreased to 30.50 from 31.00 (p <0.001). However, sputum purulence mean rank and hospital admission mean rank were not significantly decreased (p>0.05). In Group B, SGRQ decreased from 54.10±9.11 to 53.70 ±10.99 (p=0.821), CAT score decreased from 19.34±3.36 to 18.72±4.26 (p=0.302) and 6MWD increased from 363.90±20.53m to 364.93±26.09m (p=0.775). However, no impact was noted on sputum amount, sputum purulence and hospital admission (p>0.05).

Moreover, while SGRQ, CAT and 6MWD were significantly better in group A than group B (p=0.002, 0.002 and 0.024 respectively), sputum quantity, sputum purulence and hospital admission showed no significant difference (p=0.089, 0.161 and 0.154 respectively).

Conclusion: Pulmonary rehabilitation has a favourable effect on quality of life in patients with COPD in comparison to N-acetyl cysteine and should be a regular part of treatment of COPD.


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To asses resistance and prevalence of MTB in EPTB

N. M. Aleemuddin, Ashfaqhasan, S. Mahmood, Fahad, G. Vinay, Saleem


Deccan College of Medical Sciences, Princess ESRA Hospital, Hyderabad, Telangana, India. E-mail: aleem95@yahoo.com

Aim and Objective: To asses the prevalence, resistance patterns of Mtb in EPTB and also yields of smear and cultures in EPTB.

Materials and Methods: 147 samples were tested for Mtb in a cross sectional study over two years using a combination of bacteriological studies. Clinical specimens were collected through fine needle aspiration, pleural tap, excision biopsy and CT guided aspiration based on the site involved. Microbiological analysis was done using direct microscopy by ZN stain and culture. Midlle Brook 7H9 broth for automated TB culture system [MGIT320] and Lowenstein Jenson media [LJ] for were used for isolation of mtb. Mtb species confirmation was achieved by mycobacterial protein antigen i.e. MPT 64. Drug susceptibility test for first line antituberculosis drugs was carried out using readymade kit called SIRE.

Results: Thirty-nine (26.5%) samples were found positive bacteriologically, by either direct microscopy, culture or by both out of the 147 EPTB suspects analysed. Smear alone in 13 [9%], culture alone in 14 [9.5%] and culture and smear both in 12 [8%]. Overall, culture positivity was around 18%. MGIT 320 system and LJ media together could detect 6/26 (23%); LJ media alone could detect 2/26 (8%). MGIT alone could detect 18/26 (69%) of isolates. 26 strains of Mtb were isolated and confirmed by MPT64 antigen Four strains (15%) were showing resistance to first line anti-tuberculosis drugs. The rest of the strains were pan susceptible. Majority of the samples received were pleural effusion accounting for 72/147 [49%] followed by peripheral lymph nodes 39/147 [27%], gastrointestinaL 17/147 [12%], osteo articular 11/147 [7%], pus 5/147 [3%] and genitourinary in 3/147 [2%], respectively. In the present study, lymph node tuberculosis was the predominant type having 12/26 [46%] of the positive cases followed by pleural effusion in 5/26 [19%], osteo articular in 4/26 [15%], pus in 2/26 [8%], gastrointestinal in 2/26 [8%] and genito urinary in1/26 [4%].

Conclusion: Eighteen percent (18%) of EPTB samples were found to be culture positive for Mtb. Fifteen percent (15%) of the Mtb strains were found to be resistant to the first line drugs used in treatment of tuberculosis.

VAP in patients with initial normal chest X-ray

Akhil Paul, Devasahayam Jesudas Christopher, Balamugesh Thangakunam, Peter John Victor, Subramani Kandasamy


Christian Medical College, Vellore, Tamil Nadu, India. E-mail: akhil_pauli@yahoo.com

Aim and Objective: To determine the clinical-microbiological profile and predictive factors of outcome and incidence of 'Ventilator Associated Pneumonia' in patients with a normal chest x ray at intubation including Modified CPIS, APACHE-III, MOD -Scores and S.Procalcitonin level.

Materials and Methods: Prospective Cohort study. All intubated patients admitted in ICUs during the study period of 12 months, with a normal Chest xray at the time of intubation were included once they develop clinico-radiological evidence of pneumonia. Diagnosis of VAP was made based on Modified CDC criteria- 2014 guidelines. They were followed up for the rest of the ICU and hospital stay.

Results: 37.18% had early VAP. 57.69% had polymicrobial growth in the ET aspirate culture. Acinetobacter was the most commonest. Mean Procalcitonin level among those who died was 35.36. The median survival for patients with APACHE-III score.

Conclusion: Late VAP was more common than Early VAP. APACHE III score was a good predictor of mortality, number of days of ICU and hospital stay. Modified CPIS score was a predictor of the median survival in terms of ICU days whereas MODS score was a predictor of mortality as well. Age > 45 was a risk factor for mortality. Polymicrobial infection increased the ICU and the hospital stay.

Pleural fluid biomarkers in TB effusion

A. Ashwin Oliver, D. J. Christopher, Victoria Job


Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: drashwin1985@gmail.com

Aim and Objective: To study the role of pleural fluid biomarkers- ADA, ADA2 and Interferon gamma and study the combination of biomarkers in the diagnosis of tuberculous pleural effusion.

Materials and Methods: 154 patients, between May 2012 and July 2013 with exudative pleural effusion were included in the study after informed consent. All patients underwent pleural aspiration; biopsy and the samples were sent for analysis. The study sample was analyzed for the biomarkers. The frequencies and percentage are calculated for the biomarkers and the sensitivity, specificity; positive predictive, negative predictive value was done using ROC analysis. The area under the curve and cutoff values for biomarkers were calculated.

Results: Among the 154 patients, 68 patients had tuberculosis. The mean age of the patients was 44.8 years with a male predominance of 74% and 94 % were unilateral effusions. Tuberculous effusion was commonly seen in age group less than 40 years with male predominance. 80% of the patients had lymphocytic effusion. Higher protein levels (mean=5.4mg/dl) was seen in tuberculosis. The yield of pleural cultures was low and pleural biopsy culture had a better yield than pleural fluid culture. The yield of pleural fluid cytology was 45%. ADA had a sensitivity of 70.1 % with a specificity of 71.1%. ADA2 had a better sensitivity than ADA but lacks specificity. Interferon gamma had a better specificity and specificity than ADA and ADA2. The sensitivity was 80% and specificity was 87%. The combination of biomarkers improved the sensitivity but failed to improve the specificity. ADA and Interferon gamma levels were found elevated in tuberculous pleural effusion. A combination of ADA > 40U/L with Interferon gamma >3.12IU/L in pleural fluid improves the diagnostic yield in tuberculous pleural effusion but cannot replace the gold standard, culture and histopathology.

Conclusion: ADA2 had better sensitivity than ADA. Interferon gamma had better sensitivity than ADA and ADA2. A combination of ADA >40U/L with Interferon gamma >3.12IU/L improved the diagnostic yield in tuberculous pleural effusion.

Role of Culture in Community Acquired Pneumonia

A. B. Athira, C. Davis Paul, Thomas George, C. S. Ajith Kumar, C. P. Muraly, O. K. Mani


Government Medical College, Thrissur, Kerala.

E-mail: emaraldab@yahoo.co.in

Aim and Objective: Community-acquired pneumonia (CAP) presents both a diagnostic and therapeutic challenge to clinicians despite the availability of potent new antimicrobials and effective vaccines. This is because of the non-specificity of clinical and radiographic findings and the limitations of diagnostic tests for identifying an etiologic pathogen and thus most initial therapy is necessarily empirical. There is a controversy in the role of culture tests in diagnosis of CAP in different guidelines. So this study was done to identify the utility of culture in our setting. To determine the positivity rate of cultures performed in patients with CAP.

Materials and Methods: A prospective observational study was done in patients with CAP who were started on empirical antibiotic treatment and performed sputum and blood culture examination from January 2015 to June 2015. Co-morbidities and other relevant patient characteristics were identified to address factors related to the etiology of CAP.

Results: The study included 70 patients of CAP. Sputum culture was positive in 32 (45.7%), blood culture in 30 (42.9%) and both culture in 12 (17.1%). The sputum & blood culture was negative in 35 (50%) and 32 (45.7%). Common isolates were Streptococcus pneumonia (11), Klebsiella (10) and staphylococcus (6). 2 (2.9%) were Burkholderia. Most common co-morbidity was diabetes. Antibiotics was changed according to C & S in 27 (38.6%).

Conclusion: Cultures were useful in identifying organism and selecting appropriate antibiotics in good number of patients. It is helpful in identifying pneumonia by rare organism like Burkholderia.

Yield of CXR in lung diseases in comparison to CT

P. Shibini, Davis Paul, Thomas George


Government Medical College, Thrissur, Kerala.

E-mail: shibinip@gmail.com

Aim and Objective: With the availability of CT in most hospitals there is a tendency among physicians to go for CT irrespective of its benefit forgetting the fact that one CT has radiation equivalent to 70 CXR. Knowing the additional yield may help us to avoid the misuse of CT thorax. The aim of study is to compare diagnostic yield of CXR and CT in pulmonary diseases.

Materials and Methods: This is a blinded observational comparative study was conducted on 89 patients with definite diagnosis who underwent both CXR and CT as part of their evaluation. X-rays and CT performed on the same patients were matched. X-ray was interpreted independently by two pulmonologists with adequate experience and CT by a radiologist with adequate experience. The correlation between CT and X-ray findings were compared.

Results: CXR has 100% sensitivity and specificity in diagnosing PTB sequelae compared to CT(p <0.001) Whereas sensitivity & specificity in other lung diseases were a) Bronchiectasis 76.4% and 100% b) DPLD 71.4% and 96.3% (P<0.001) c) Lung mass was 57% and 83.3%( P=0.003) d) Mediastinal mass 25% and 98.2% e) Pneumonia 66.67% and 85.4%( P=0.01).Inter-observer correlation in diagnosing PTB sequelae was kappa=1, which is statistically significant. The overall Pearson correlation coefficient between CXR & CT is 0.7 & the inter-observer correlation coefficient was 0.97.

Conclusion: CT has no significant advantage in diagnosing PTB sequelae but has advantage in mass lesions.

Thoracoscopy in undiagnosed pleural effusion

Dheeraj Sharma, Ramakant Dixit, Neeraj Gupta, Chetan Basavaraj Patil, Ankur Gupta, Sathyadeep Verma


JLN Medical College, Ajmer, Rajasthan, India.

E-mail: sabarigirivasan103@gmail.com

Aim and Objective: Undiagnosed pleural effusion is often a difficult clinical situation that needs further histological study for a definitive etiological diagnosis.Medical thoracoscopy is a minimal invasive procedure with a minor morbidity and mortality risk that with better yield than closed pleural biopsy.

Materials and Methods: We performed rigid thoracoscopy in 117 consecutive cases of undiagnosed exudative pleural effusion. Clinical, radiological and histopatological data of the patients were collected prospectively and analysed.

Results: The overall diagnostic yield of thoracoscopic pleural biopsy was 83.8% in patients with undiagnosed pleural effusion. Histopahologial diagnosis included malignancy in 52.1% patients, both primary pleural malignancy (mesothelioma) and metastatic pleural carcinoma from lung and other organ. Tuberculosis in 26.5%, others including paraneumonic effusion(4),multipal myeloma(1), lupus pleurits(1) and pulmonary langherhans cell histiocytosis(1). 16.2% of patients still remained undiagnosed. Procedure related mortality was nil. Other minor complication related to the procedure include bleeding, subcutaneous emphysema and tract malignancy.

Conclusion: The diagnostic thoracoscopy in local anaesthia is a simple, relatively safe and low cost investigation with high diagnostic yield, no mortality and a low morbidity.

Role of Gene Xpert in Exudative pleural effusion

Tinku Joseph, Arun Nair, Asmita Mehta, Nithya Haridas, P. T. James


Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: tinkujoseph2010@gmail.rcom

Aim and Objective: To find out whether Gene Xpert could be used for the rapid diagnosis of tuberculous pleural effusion. Comparison of Gene Xpert with pleural fluid BACTEC culture, biopsy and ADA results.

Materials and Methods: This was an observational study conducted at tertiary care teaching institute. 110 consecutive patients with lymphocytic exudative pleural effusion were subjected to pleural fluid culture (BACTEC), Adenosine Deaminase (ADA), and Xpert MTB/RIF (real time PCR using centrifuged sample). All the patients were studied prospectively. BACTEC culture results, Histopathology (pleural biopsy) and or clinical radiological resolution served as the reference standard for diagnosis of TB. Statistical analysis was performed with the SPSS for Windows (version 11.0) software package.

Results: Total 110 exudative pleural effusion patients were evaluated in the study. Out of which gene xpert was positive in 11.27%, BACTEC culture was positive in 3.57%, Pleural biopsy was positive in 46.6% and ADA showed positivity of 63.6%. Also pleural fluid gene xpert showed 100% sensitivity and 93% specificity when compared with BACTEC culture results. When gene xpert results were compared with pleural biopsy results it showed a sensitivity of 50 % and specificity of 96.6% respectively.

Conclusion: We would like to conclude that the role of Xpert MTB/RIF assay in diagnosing TB effusion is very limited. The yield of the test was comparable to BACTEC but inferior to histopathology. The present study showed that Xpert MTB/RIF has 100% sensitivity and 92.6% specificity when compared with BACTEC culture (gold standard diagnostic modality for pleural TB). Further larger studies are required to confirm the findings.

Vitamin D deficiency & bronchial asthma

Nikhil Sarangdhar, Agam Vora, K. C. Mohanty


K. J. Somaiya Medical College, Mumbai, Maharashtra, India. E-mail: ncsarangdhar@rocketmail.com

Introduction: Vitamin D is known to play an role in boosting innate and adaptive immunity and macrophage activity. Vitamin D deficiency has been proven to be a predisposing factor for the development of Tuberculosis and its pathologic association with respiratory disorders like Tuberculosis and COPD is well documented. However in bronchial asthma, its exact role remains to be determined.

Aims and Objectives: (1) To study the correlation between serum Vitamin D levels in patients of difficult to control bronchial asthma in accordance with disease severity. (2) To document improvement in asthma control after Vitamin D supplementation and correlate it with lung function.

Materials and Methods: Serum Vitamin D levels were measured and found to be low in 57 non-smoker patients of difficult to control asthma between 18-55 years of age who were uncontrolled even after courses of oral glucocorticosteroids and other maximally optimised medical treatment for bronchial asthma along with treatment of other co-morbidities like gastro-oesophageal reflux and allergic rhinitis. The average serum Vitamin D level was 13 U. These patients were treated with Calcium and Vitamin D supplementation and were re-evaluated after 3 months with repeat Vitamin D levels, spirometry and peak flow rate.

Results: All (57 out of 57) patients showed significant improvement in spirometry and peak flow rate variability. 20 (35.1%) out of 57 patients also showed modest improvement in terms of serum Vitamin D levels. This was found to be statistically significant (p<0.05).

Conclusion : This study reveals a strong correlation between Vitamin D deficiency and difficult to control asthma.




 

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