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   Table of Contents - Current issue
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January-February 2020
Volume 37 | Issue 1
Page Nos. 1-96

Online since Tuesday, December 31, 2019

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EDITORIAL  

Liquid biopsy for T790M mutation detection: A ray of hope? Highly accessed article p. 1
Anant Mohan, Saurabh Mittal
DOI:10.4103/lungindia.lungindia_543_19  PMID:31898612
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ORIGINAL ARTICLES Top

A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: Randomized trial Highly accessed article p. 3
Kavitha Venkatnarayan, Gopi C Khilnani, Vijay Hadda, Karan Madan, Anant Mohan, Ravindra M Pandey, Randeep Guleria
DOI:10.4103/lungindia.lungindia_335_19  PMID:31898613
Background: The optimal strategy for the withdrawal of noninvasive ventilation (NIV) remains unknown. This study was planned to compare three different strategies for the withdrawal of NIV among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory failure (HcRF). Materials and Methods: Patients with AECOPD with HcRF who improved on NIV were randomized into three groups – immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C) of NIV. The probability of successful withdrawal was compared among the groups. Results: This study included 90 patients (males – 86.6%) with a mean (±standard deviation [SD]) age of 59.9 ± 8.3 years. The mean (±SD) pH and PaCO2 at admission were 7.23 ± 0.04 and 84.4 ± 12.0 mm Hg, respectively. The duration of NIV received before randomization was 31.6 ± 9.2 h with maximum inspiratory positive airway pressure and expiratory positive airway pressure of 17.6 ± 2.7 cm H2O and 7.4 ± 1.4 cm H2O, respectively. NIV was successfully withdrawn in 23/30 (76.6%) in Group A, 27/30 (90%) in Group B, and 26/30 (86.6%) in Group C (P = 0.31). The total duration of NIV use and length of hospital stay was lower in Group A and B as compared to Group C (P = 0.001). Conclusions: Immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible. Immediate withdrawal did not increase the risk of weaning failure from the NIV.
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Clinical profile and course of children with postinfectious bronchiolitis obliterans from a tertiary care hospital p. 8
Krishna Mohan Gulla, Kana Ram Jat, Rakesh Lodha, Sushil K Kabra
DOI:10.4103/lungindia.lungindia_145_19  PMID:31898614
Background: Postinfectious bronchiolitis obliterans (PIBO) is a chronic obstructive lung disease with scanty information in literature on etiology, clinical profile, treatment, and outcome. Objective: The objective of the study is to describe the clinical profile and course of children diagnosed with PIBO. Methods: A chart review of children below 18 years of age diagnosed as PIBO over the past 9 years was carried out. Details of clinical profile, laboratory investigations, imaging, treatment received, and outcome were recorded. Results: Eight children (boys 4) with PIBO were identified. Median (interquartile range [IQR]) age at the first episode of acute severe bronchiolitis such as illness and diagnosis of PIBO was 15 (6, 23.5) and 30 (16.5, 60) months, respectively, indicating a delay in diagnosis. The most common symptoms were recurrent episodes of cough (100%), fast breathing (100%), wheezing (87.5%), and fever (62.5%). Median (IQR) number of hospitalizations and episodes of antibiotic use prior to diagnosis were 2.5 (2, 5.5) and 2 (2, 4), respectively. Three (37.5%) children received mechanical ventilation during previous hospitalizations. Chest computed tomography revealed mosaic attenuation in 8 (100%), ground-glass opacities in 2 (25%), and bronchial wall thickening in 2 (25%). After diagnosis, 7 received oral steroids, 7 received hydroxychloroquine, 5 received azithromycin, and 2 received azathioprine. The median (IQR) duration of follow-up (n = 6) was 6 (1.5, 9.5) months. Median (IQR) number of pulmonary exacerbations in follow-up was 2 (1, 5). Conclusion: PIBO is still an under-recognized entity with substantial delay in diagnosis and unnecessary use of antibiotics. Clinical course with imaging findings may help to diagnose and manage this entity.
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T790M mutations identified by circulating tumor DNA test in lung adenocarcinoma patients who progressed on first-line epidermal growth factor receptor-tyrosine kinase inhibitors p. 13
Vinodini Merinda, Gatot Soegiarto, Laksmi Wulandari
DOI:10.4103/lungindia.lungindia_182_19  PMID:31898615
Background: Plasma circulating tumor deoxyribonucleic acid (ctDNA) test is an alternative method to detect the T790M mutation. Compared to conventional tumor rebiopsy, ctDNA possesses several advantages including less invasive, faster, lower costs, and having minimal risk of complications for patients. Objective: The main objective of the study is to identify the prevalence of T790M mutations in lung adenocarcinoma patients who progressed after tyrosine kinase inhibitors (TKIs) therapy using ctDNA examination. Materials and Methods: This was a retrospective cohort study based on medical records of lung adenocarcinoma patients in the Oncology Outpatient Clinic of Dr. Soetomo General Hospital within the period of January 2017–June 2018. Patients who progressed after receiving first-line epidermal growth factor receptor-TKI (EGFR-TKI) undergone plasma ctDNA examination and genotyping using digital platforms (Droplet Digital™ PCR) method. Results: In total, there were 39 patients who met the criteria for ctDNA testing. Thirty-three patients (84.6%) received first-line gefitinib, while the other six (15.4%) received erlotinib. The T790M mutations were detected in 46.2% of patients. In addition, EGFR common mutation in exon 19 and exon 21 were detected in 87.2% of patients. Median progression-free survival of patients receiving first-line gefitinib or erlotinib were both around 9 months and did not differ significantly. Conclusions: CtDNA examination successfully detected T790M mutation in a certain proportion of lung adenocarcinoma patients who progressed after first-line EGFR-TKI without the need for difficult and invasive rebiopsy.
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Predictors of mortality in acute exacerbations of chronic obstructive pulmonary disease using the dyspnea, eosinopenia, consolidation, acidemia and atrial fibrillation score p. 19
Avya Gopal Bansal, Gajanan S Gaude
DOI:10.4103/lungindia.lungindia_114_19  PMID:31898616
Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common and often fatal; however, accurate prognosis of patients hospitalized with an exacerbation is difficult. The Dyspnea, Eosinopenia, Consolidation, Acidemia, and Atrial Fibrillation (DECAF) score uses indices routinely available at the time of hospital admission and can accurately predict the inhospital mortality and outcomes in patients hospitalized with AECOPD. Methodology: A cross-sectional study was conducted in Jawaharlal Nehru Medical College, Belagavi, from January 2016 to June 2018. Consecutive patients hospitalized with an exacerbation of chronic obstructive pulmonary disease were included. DECAF indices and inhospital death rates were recorded. The prognostic value of DECAF was assessed by comparing the total score with the inhospital mortality. Statistical analysis was done using SPSS version 20. Results: Two hundred and twenty-eight patients were recruited. The mean (standard deviation) age was 61.09 ± 10.6 years; 73.68% were male and 48 patients (21.05%) died in hospital. One hundred and twelve patients were identified as low risk (DECAF: 0–1) with 6 (5.4%) patients dying in the hospital and 56 patients were identified as high risk (DECAF: 3–6) with an inhospital mortality of 60.1%. Length of stay for scores of 0–1, 2, and ≥3 was 6.42, 7.47, and 9.64 days, respectively, with P < 0.05. The receiver operating characteristic curve analysis showed P < 0.001, thereby proving that the DECAF is a significant predictor of mortality in AECOPD. Conclusion: This study proved that with an increase in the DECAF score, the mortality among patients in AECOPD increased. The DECAF score helps clinicians predict prognosis accurately by identifying low-risk patients potentially suitable for home-based care or early hospital discharge and high-risk patients requiring escalated palliation with high-level care to improve their outcome.
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Comparison of tuberculin skin test and QuantiFERON-TB Gold In-Tube test in Bacillus Calmette–Guerin-vaccinated children p. 24
Ira Shah, Jagdish Kathwate, Naman S Shetty
DOI:10.4103/lungindia.lungindia_304_19  PMID:31898617
Objectives: The aim of this study is to determine the concordance between QuantiFERON-TB Gold In-Tube (QFT-GIT) and tuberculin skin test (TST) in children vaccinated with Bacillus Calmette–Guerin (BCG). Methods: This cross-sectional study was done at a pediatric tertiary care center in 33 BCG-vaccinated children aged 6 months–15 years suspected of Mycobacterium tuberculosis infection or in contact with a patient with open tuberculosis (TB). All patients were tested for TST with purified protein derivative-S 5 tuberculin units and QFT-GIT assays. Concordance was evaluated between TST and QFT assay by kappa coefficient (k). Agreement between the tests was classified into categories: poor if k < 0.20, fair (k = 0.21–0.40), moderate (k = 0.41–0.60), good (k = 0.61–0.80), and very good (k = 0.81–1.00). Results: Both the TST and QFT assay were positive in 13 and negative in eight children, respectively, resulting in an agreement of 63% (κ = 0.31). Eight children were <4 years of age of which only one patient had a positive TST and QFT-GIT, and TST and QFT-GIT were negative in two patients resulting in an agreement of 37.5% (κ = 0.063). Among children 4 years of age and older, 12 patients had a positive TST and QFT-GIT and 6 patients had a negative TST and QFT-GIT resulting in an agreement of 72% (κ = 0.41). Among 12 children who had been in contact with an adult having open TB, both the TST and QFT-GIT were positive in 6 patients and negative in two patients, respectively, resulting in an agreement of 66% (κ = 0.41). TST specificity was only 29.6% with a positive predictive value of 42.4% as compared to QFT-GIT. Among children <4 years of age, TST specificity was only 28.6% with a positive predictive rate of 16.7%, and among children >4 years of age, TST specificity was 50% with a positive predictive value of 66.7%. In patients with contact with a patient having TB, TST specificity was 33.3%. Considering TST of 15 mm and above as positive, TST specificity increased to 63.2% and a positive predictive value was 56.3%. Conclusion: The concordance of TST and QFT-GIT is low in children with previous BCG vaccination and especially in children <4 years of age. QFT-GIT may help to rule out false-positive TST.
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Regression equations of respiratory impedance of Indian adults measured by forced oscillation technique p. 30
Sajal De, Nalok Banerjee, Gagan Deep Singh Kushwah, Dharmendra Dharwey
DOI:10.4103/lungindia.lungindia_260_19  PMID:31898618
Background: Forced oscillation technique (FOT) is a technique to measure the mechanical properties of the lung. The present study was aimed to develop regression equations of within- and whole-breath respiratory impedance (Zrs) of healthy Indian adults. Methods: Total 323 adults were sequentially screened. Smokers, individuals with respiratory symptoms or diseases, and unable to perform acceptable FOT were excluded. Within- and whole-breath resistance (Rrs) and reactance (Xrs) were measured at 5, 11, and 19 Hz by Resmon Pro® Full device. The regression equations of within- and whole-breath Rrs and Xrs were generated separately for men and women by multiple linear regression models. Results: The FOT data of 253 individuals (122 men) aged 18–81 years were included in the analysis. The magnitudes of whole-breath Rrs at 5 Hz (4.53 ± 1.05 cmH2O/L/s in women vs. 3.26 ± 1.05 cmH2O/L/s in men; P = 0.000) and whole-breath Xrs at 5 Hz (−1.23 ± 0.66 cmH2O/L/s in women vs. −1.00 ± 0.54 cmH2O/L/s in men; P = 0.003) of women were significantly of higher magnitude as compared to men. The standing height was the best determinant of Zrs, followed by body weight; the effect of age was negligible and was observed in men only. The magnitudes of both Rrs and Xrs decrease with an increase in standing height of both men and women. Conclusions: The present study provides regression equations of within- and whole-breath respiratory impedance of Indian adults.
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Endoscopic ultrasound-guided-fine-needle aspiration/fine-needle biopsy in diagnosis of mediastinal lymphadenopathy – A boon p. 37
Parmeshwar Ramesh Junare, Samit Jain, Pravin Rathi, Qais Contractor, Sanjay Chandnani, Sangeeta Kini, Ravi Thanage
DOI:10.4103/lungindia.lungindia_138_19  PMID:31898619
Background/Objectives: Evaluation of mediastinal lymphadenopathy (MLA) is a great diagnostic challenge considering the myriad of causes. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of MLA due to its safety, reliability, and accuracy. The present study details the role of EUS-guided-fine-needle aspiration/fine-needle biopsy (EUS-FNA/FNB) in MLA of unknown origin. Methods: Seventy-two patients (34 men) with MLA of unknown etiology were studied. Mediastinum was evaluated with linear echoendoscope and FNA/FNB was performed with 22-G needle and sent for cytology, histopathological, and mycobacterial growth indicator tube/GeneXpert evaluation. EUS-FNA/FNB diagnosis was based on cytology reporting by pathologists. Patients tolerated the procedure, and insertion of needle into the lesion was always successful without any complications. Results: EUS-FNA/FNB established a tissue diagnosis in 66/72 patients in first sitting, while six patients underwent repeat procedure. EUS-FNA diagnoses (after second sitting) were tuberculous lymphadenitis in 45/72 (62.5%), metastatic lymph nodes 12/72 (16.7%), reactive lymphadenopathy 6/72 (8.3%), sarcoidosis 4/72 (5.6%), and lymphoma 2/72 (2.8%), while it was nondiagnostic in 3/72 (4.1%) patients. Final diagnosis was based on combined clinical presentation, EUS-FNA/FNB result and clinicoradiological response to treatment on long-term follow-up of 6 months. Conclusion: EUS echo features along with EUS-FNA/FNB can diagnose MLA and surgical biopsy can be avoided.
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SYSTEMATIC REVIEW Top

Prevalence of pulmonary tuberculosis in India: A systematic review and meta-analysis p. 45
Ramadass Sathiyamoorthy, Mani Kalaivani, Praveen Aggarwal, Sanjeev Kumar Gupta
DOI:10.4103/lungindia.lungindia_181_19  PMID:31898620
The Revised National Tuberculosis Control Program was started in India in 1997. There has been no nationwide survey to assess the prevalence of pulmonary tuberculosis. We aimed to conduct a systematic review and meta-analysis of published literature to provide an estimate of the prevalence of pulmonary tuberculosis in India. Several databases including Medline, Embase, Scopus, the Cochrane Library, Web of Science, and Google Scholar were searched for studies published between January 1, 1997, and December 31, 2018, which reported the prevalence of pulmonary tuberculosis. Community-based cross-sectional studies conducted among population aged 15 years and above were included. Summary estimates were calculated using random effects models. We identified 13 articles with 16 individual studies having screened 961,633 individuals for pulmonary tuberculosis. The pooled prevalence of bacteriologically positive pulmonary tuberculosis was 295.9 (95% confidence interval: 201.1–390.6) per 100,000 population. The prevalence was higher among males than females and in rural areas compared to urban areas. The pooled prevalence of culture-positive pulmonary tuberculosis (277.8/100,000 population) was higher than smear-positive pulmonary tuberculosis (196.6/100,000 population). The pooled prevalence of bacteriologically positive pulmonary tuberculosis in sensitivity analysis was 186.6/100,000 population. In all these estimates, heterogeneity remained high and significant publication bias was observed. The prevalence of pulmonary tuberculosis varied based on sex and distribution of population in rural and urban areas. There is a need of nationwide population-based survey to estimate the burden of tuberculosis to inform control measures and facilitate monitoring and evaluation.
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CASE REPORTS Top

Case of urinothorax – A rare presentation p. 53
Aditya Kumar Chawla, Gaurav Chaudhary, Madhav Kumar Chawla, Rakesh Chawla, Primal Sachdeva Chawla
DOI:10.4103/lungindia.lungindia_95_19  PMID:31898621
Urinothorax (UT) is a rare and often undiagnosed condition, defined as the presence of urine in the pleural cavity due to the retroperitoneal leakage of urine (known as urinoma) into the pleural space. It is a rare cause of pleural effusion and is secondary to traumatic or obstructive reasons. UT is usually a transudate pleural effusion. Its diagnosis requires a high degree of clinical suspicion, because the respiratory symptoms tend to be absent or mild and urological signs tend to dominate. Thoracocentesis followed by measurement of creatinine in the pleural fluid is a procedure to establish the true diagnosis. The average pleural fluid-to-serum creatinine ratio is in the range of 1.09–19.8. Pleural fluid-to-serum creatinine ratio >1 is the diagnostic criterion of UT. We report a case of UT associated with trauma.
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A case report evaluating combined effect of intensity-modulated radiotherapy and deep inspiratory breath-hold for mediastinal lymphoma: A dosimetric analysis p. 57
Abhinav Dewan, Kundan Singh Chufal, Sarthak Tandon, Irfan Ahmad, T Suresh, Ajay Dewan, Anjali Pahuja
DOI:10.4103/lungindia.lungindia_88_19  PMID:31898622
Excellent survival has been reported after combined modality treatment in bulky mediastinal Hodgkin's lymphoma. Late effects such as cardiac morbidity and secondary cancers have been reported after radiotherapy (RT), especially in young adults. Advanced RT techniques such as deep inspiratory breath-hold (DIBH), intensity-modulated RT (IMRT), and volumetric arc therapy have been used recently to reduce these late effects with encouraging results. We hereby present a case report evaluating combined effect of DIBH and IMRT in a young adult with mediastinal lymphoma.
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A novel procedure of endobronchial ultrasound-guided transbronchial needle aspiration for pulmonary parenchymal lesions: The ZUTAM technique p. 63
Mario Tamburrini, Siva Prasad Reddy, Vivek Gundappa, Lokesh Yagnik, Piera Peditto, Dipti Gothi, Umberto Zuccon
DOI:10.4103/lungindia.lungindia_187_19  PMID:31898623
Convex probe-endobronchial ultrasound (CP-EBUS) has been proven to be safe and accurate for identifying malignancy and granulomatous disease affecting the mediastinum and hilum. CP-EBUS can be used for intraparenchymal lesions also and has been shown to be efficacious. A subset of lesions particularly suited for CP-EBUS are those completely surrounded by lung parenchyma, centrally located, and typically close to but without an airway leading directly to them. We report a case of transbronchial needle aspiration (TBNA) done from a nodule of size 11 mm in the superior segment of the right lower lobe. EBUS-TBNA was done from this lesion, which was 5 mm away from the bronchus in the lung parenchyma with intervening normal lung tissue in between. TBNA was performed by compressing the abutting normal lung tissue, thus causing compression collapse of the intervening normal lung. We labeled this Zealous Unique Trans Arterial Maneuver as the “ZUTAM” technique.
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PICTORIAL QUIZ Top

Mediastinal mass mimic p. 66
Ananda Datta, Mahismita Patro, Dipti Gothi
DOI:10.4103/lungindia.lungindia_124_19  PMID:31898624
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CASE LETTERS Top

A rare case of lung adenocarcinoma: Unusual presentation with miliary mottling p. 69
Pankaj Goyal, Sneha J Bothra, Parveen Jain, Udip Maheshwari, Chaturbhuj Agarwal, Dinesh Chandra Doval
DOI:10.4103/lungindia.lungindia_71_19  PMID:31898625
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Gefitinib-induced pyogenic granuloma in a patient with lung cancer p. 71
Satyajeet Sahoo, Chandra Sekhar Sirka, Saroj K Das Majumdar, Prasanta Raghab Mohapatra
DOI:10.4103/lungindia.lungindia_277_19  PMID:31898626
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From symptom and sign to diagnosis in a case of pulmonary plasmacytoma and pulmonary metastasis p. 72
Mihaela Maria Ghinea, Andreea Georgiana Stoica, Sabina Livia Ciocodei
DOI:10.4103/lungindia.lungindia_256_19  PMID:31898627
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RESEARCH LETTERS Top

Osteosarcoma mimicking fibrous pleurisy with dystrophic calcification!!! p. 75
Tahira Sultana Kumar, Ashish Chawla
DOI:10.4103/lungindia.lungindia_274_19  PMID:31898628
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Osimertinib as an emerging therapeutic modality in nonsmall cell lung cancer: Opportunities and challenges in Indian scenario p. 77
Sayanta Thakur, Dwaipayan Sarathi Chakraborty, Sandeep Lahiry, Shouvik Choudhury
DOI:10.4103/lungindia.lungindia_291_19  PMID:31898629
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Intercostal chest drain clamping p. 79
René Agustín Flores-Franco
DOI:10.4103/lungindia.lungindia_417_19  PMID:31898630
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The effects of obesity on pulmonary function in adults with asthma p. 80
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/lungindia.lungindia_406_19  PMID:31898631
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CORRESPONDENCE Top

Assessing the flat diaphragm in chronic obstructive pulmonary disease: Deep-diving is a better approach p. 82
Uma Devaraj, Kavitha Venkatnarayan, Uma Maheswari Krishnaswamy, Priya Ramachandran
DOI:10.4103/lungindia.lungindia_306_19  PMID:31898632
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Ultrasonography of diaphragm in chronic obstructive pulmonary disease: Unanswered questions p. 83
Vijay Hadda, Pawan Tiwari, Saurabh Mittal, Karan Madan, Anant Mohan
DOI:10.4103/lungindia.lungindia_312_19  PMID:31898633
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Ultrasonography in chronic obstructive pulmonary disease: Fact or fiction? p. 84
Jaber S Alqahtani, Saeed M Alghamdi
DOI:10.4103/lungindia.lungindia_375_19  PMID:31898634
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GENERAL PERSPECTIVE Top

Bronchial thermoplasty for severe asthma: A position statement of the Indian chest society p. 86
Karan Madan, Saurabh Mittal, Tejas M Suri, Avinash Jain, Anant Mohan, Vijay Hadda, Pavan Tiwari, Randeep Guleria, Deepak Talwar, Sudhir Chaudhri, Virendra Singh, Rajesh Swarnakar, Sachidanand J Bharti, Rakesh Garg, Nishkarsh Gupta, Vinod Kumar, Ritesh Agarwal, Ashutosh N Aggarwal, Irfan I Ayub, Prashant N Chhajed, Amit Dhamija, Raja Dhar, Sahajal Dhooria, Hari K Gonuguntla, Rajiv Goyal, Parvaiz A Koul, Raj Kumar, Nagarjuna Maturu, Ravindra M Mehta, Ujjwal Parakh, Vallandaramam Pattabhiraman, Narasimhan Raghupathi, Inderpaul Singh Sehgal, Arjun Srinivasan, Kavitha Venkatnarayan
DOI:10.4103/lungindia.lungindia_418_19  PMID:31898635
Bronchial thermoplasty (BT) is an interventional bronchoscopic treatment for severe asthma. There is a need to define patient selection criteria to guide clinicians in offering the appropriate treatment options to patients with severe asthma. Methodology: An expert group formed this statement under the aegis of the Indian Chest Society. We performed a systematic search of the MEDLINE and EMBASE databases to extract evidence on patient selection and the technical performance of BT. Results: The experts agreed that the appropriate selection of patients is crucial and proposed identification of the asthma phenotype, a screening algorithm, and inclusion/exclusion criteria for BT. In the presence of atypical clinical or chest radiograph features, there should be a low threshold for obtaining a thoracic computed tomography scan before BT. The patient should not have had an asthma exacerbation in the preceding two weeks from the day of the procedure. A 5-day course of glucocorticoid should be administered, beginning three days before the procedure day, and continued until the day following the procedure. General Anesthesia (total intravenous anesthesia with a neuromuscular blocker) provides ideal conditions for performing BT. A thin bronchoscope with a 2.0 mm working channel is preferable. An attempt should be made to deliver the maximum radiofrequency activations. Middle lobe treatment is not recommended. Following the procedure, overnight observation in the hospital, and a follow-up visit, a week following each treatment session, is desirable. Conclusion: This position statement provides practical guidance regarding patient selection and the technical performance of BT for severe asthma.
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