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   Table of Contents - Current issue
Coverpage
July-August 2020
Volume 37 | Issue 4
Page Nos. 289-378

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EDITORIALS  

Practice guidelines for interstitial lung diseases: Widening the reach p. 289
Sydney B Montesi
DOI:10.4103/lungindia.lungindia_487_20  
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Tuberculosis and COVID-19 in India: Challenges and opportunities p. 292
Rajendra Prasad, Abhijeet Singh, Nikhil Gupta
DOI:10.4103/lungindia.lungindia_260_20  
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ORIGINAL ARTICLES Top

Therapeutic bronchoscopic interventions for nonmalignant central airway obstruction provide rapid and sustained improvement in symptoms and functional status p. 295
Prajowl Shrestha, Karan Madan, Vijay Hadda, Ashish Upadhyay, Saurabh Mittal, Pawan Tiwari, RM Pandey, Rakesh Garg, GC Khilnani, Randeep Guleria, Anant Mohan
DOI:10.4103/lungindia.lungindia_476_19  
Background: Central airway obstruction (CAO) is a potentially lethal condition that requires urgent endobronchial intervention and may occur due to several nonmalignant causes. The effect of these interventions on clinically relevant outcomes such as symptomatic and functional status over a period of time is, however, sparsely studied. Materials and Methods: Consecutive patients with CAO due to nonmalignant causes and undergoing various therapeutic bronchoscopy procedures were evaluated. Symptoms were assessed using the Visual Analog Scale (VAS) and Speiser score, and functional status was assessed using the 6-min walk test, spirometry, and St. George Respiratory Questionnaire (SGRQ) score at baseline and after 48 h, 4 weeks, and 12 weeks postprocedure. Results: Over 2 years, 31 patients with CAO due to nonmalignant etiology underwent 41 therapeutic bronchoscopic procedures. Majority of procedures (96.8%) were done using the rigid bronchoscope under general anesthesia. Postintubation tracheal stenosis was the most common indication (32.2%). The various procedures included, controlled radial expansion balloon dilatation of the stenotic airway (53.6%), deployment of silicone stents (19.5%), and mechanical debulking of airway tumors (16.1%). Significant improvement occurred in dyspnea and cough scores and in the Speiser score from baseline to 48 h postprocedure, and further improved at 4 weeks and 12 weeks. Similarly, the 6 min walk distance, forced expiratory volume in 1 s, and SGRQ scores progressively improved from baseline to 12 weeks. Complications occurred in 26.8% of total procedures, with no procedure-related mortality. Conclusion: Therapeutic bronchoscopy interventions provide rapid and sustained benefits in symptoms and functional status of participants with CAO of nonmalignant etiology, with an acceptable safety profile.
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Snoring time versus snoring intensity: Which parameter correlates better with severity of obstructive sleep apnea syndrome? p. 300
Souha Kallel, Khouloud Kchaou, Asma Jameleddine, Moncef Sellami, Malek Mnejja, Ilhem Charfeddine
DOI:10.4103/lungindia.lungindia_394_19  
Objective: The relationship between the severity of obstructive sleep apnea syndrome (OSAS) and both snoring intensity and rate measured objectively has not been sufficiently investigated. The aim of this study was to evaluate the relationship between severity of OSAS and snoring parameters including snoring intensity and rate. Patients and Methods: A total of 150 records of individuals who complained of snoring were analyzed. Patients were classified into four groups according to apnea–hypopnea index (AHI). Polygraphy recordings including the snoring intensity and the snoring rate (defined as the percentage of snoring time during the total sleep time) and the clinical data were compared and analyzed. Results: AHI was significantly correlated, respectively, with snoring rate (r = 0.341; P < 0.0001) and maximal intensity of snoring (r = 0.362; P < 0.0001). However, no correlation was found between the average intensity of snoring and AHI (P = 0.33). When assessing each respiratory event individually, snoring rate was more correlated with hypopnea index (r = 0.424; P < 0.0001) than with AI (r = 0.233; P = 0.004). The snoring rate (%) in the severe OSAS group (31.79 ± 19.3) was significantly higher than that in the mild OSAS group (18.02 ± 17; P = 0.001) and the control group (17 ± 16.57; P = 0.011). Similarly, the maximal intensity of snoring (db) in the severe OSAS group (90.45 ± 13.79) was higher than that in the mild OSAS group (86.46 ± 15.07; P = 0.006) and the control group (84.75 ± 6.65; P < 0.001). Conclusion: The snoring rate and maximal intensity of snoring correlate better with the severity of OSAS than average snoring intensity.
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Management of primary pulmonary alveolar proteinosis: A multicentric experience p. 304
Vikas Marwah, C D S Katoch, Sarvinder Singh, Ajay Handa, Vasu Vardhan, AK Rajput, MS Barthwal, D Bhattacharyya, SP Rai
DOI:10.4103/lungindia.lungindia_401_19  
Background: Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by alveolar accumulation of surfactant material with reduced lung function and resulting hypoxemia. It is characterized by a variable clinical course, and whole lung lavage (WLL) is the standard treatment. Herein, we report our multicentric experience of management of primary PAP. Materials and Methods: This retrospective study included patients with PAP managed at various armed forces respiratory centers from 2009 to 2019. The diagnosis of primary PAP was based on histopathologic confirmation on transbronchial lung biopsy or open lung biopsy and absence of causes of secondary PAP. We analyzed the response to WLL in these patients as well as the safety of the procedure. Results: During the above-specified period, ten patients with a diagnosis of PAP were admitted to various armed forces respiratory centers. The median age of the patients was 34.5 years (range 23–59); there were nine males (90%). The mean duration (± standard deviation) of symptoms was 10.8 (±2.70) months. For management, WLL was done for eight patients with a median volume of 23.5 L (range 18–45) per patient. All the patients showed significant symptomatic response as well as improvement in physiological parameters with no major complications. The median follow-up of all patients was 18 (range 5–44) months. Conclusions: WLL is a safe, effective therapy in an experienced setting in patients with PAP and provides long-lasting benefits.
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Exploring the effect of presence and type of allergen sensitization on fractional exhaled nitric oxide, immunoglobulin E, and interleukins 4, 5, and 13 among asthmatics p. 310
Nipun Malhotra, Nitesh Gupta, Raj Kumar
DOI:10.4103/lungindia.lungindia_493_19  
Objective: Asthma is associated with airway inflammation. Allergen sensitization (atopy) is common in asthma. This study explored the effect of food and/or aeroallergen sensitization; on airway and systemic inflammation using fractional exhaled nitric oxide (FENO) and interleukins (ILs) 4, 5, and 13. Methods: The study enrolled asthmatics (diagnosed using Global Initiative for Asthma guidelines). Atopy was diagnosed using skin-prick testing (SPT). All subjects underwent testing for FENO, blood absolute eosinophil count (AEC), and serum levels of immunoglobulin E (IgE), and ILs 4, 5, and 13. Asthmatics (BA) were classified as atopic (BA-A) and nonatopic (BA-N). Atopic-asthmatics were subclassified as exclusively food allergen (AtAA) or aeroallergen (AtAA); or dually (AtFAA) sensitized. Results: The study enrolled 203 asthmatics (BA) and 50 controls. Among BA, 169 were BA-A and 34 were BA-N. Mean values of AEC, serum IgE and FENO, and ILs 4 and 13 were significantly higher in BA-A than BA-N (659 vs. 218/mm3, 638 vs. 217 IU/ml, 39.2 vs. 20.0 ppb, 14.96 vs. 8.04 pg/ml, and 22.12 vs. 11.64 pg/ml, respectively). Meanwhile, mean IL-5 was higher in BA-A (11.01 vs. 8.76 pg/ml; P = 0.22), but not statistically significant. Subgroup analysis of atopic asthmatics (i.e., AtFA, AtAA, and AtFAA), revealed similar mean values for FENO (31.99 vs. 40.16 vs. 39.46 ppb), AEC (691.00 vs. 653.07 vs. 659.88/mm3), IgE (635.60 vs. 630.32 vs. 646.39 IU/ml), IL-4 (12.63 vs. 14.74 vs. 15.44 pg/ml), and IL-13 (18.38 vs. 19.87 vs. 24.57 pg/ml). No difference was observed among subgroups of atopic-asthmatics. Conclusion: Subgroups of atopic-asthmatics did not show any consistent difference across all the studied parameters.
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Image-guided catheter drainage in loculated pleural space collections, effectiveness, and complications p. 316
Suhail Rafiq, Musaib Ahmad Dar, Imran Nazir, Fahad Shaffi, Feroze Shaheen, Ishfaq Ayoub Kuchay
DOI:10.4103/lungindia.lungindia_385_19  
Introduction: Image-guided drainage is an established technique with a multitude of applications. The indications, techniques, and management of image-guided catheter drainage, however, continue to evolve. Image-guided drainage alone is sometimes sufficient for the treatment of a collection, but it can also act as an adjunct or temporizing measure before definitive surgical treatment. Drainage of a symptomatic collection is performed to drain pus from the cavity, working in conjunction with antibiotics. Infected collections accumulate antibiotics to a limited extent, which generally precludes effective treatment with antibiotics alone unless the collection is very small (1–3 cm). There are many indications for image-guided drainage in the chest, including pleural disease, lung parenchymal, pericardial, and mediastinal collections. Pleural collections represent a common clinical problem, for which image-guided drainage is recommended to reduce complications encountered as a result of blind drainage. Aim and Objective: To evaluate the efficacy and complications of ambulatory catheter drainage system for infective and loculated pleural collection. Materials and Methods: The study was conducted in the department of radiodiagnosis and imaging, Sheri Kashmir Institute of Medical Sciences Srinagar 2016 to 2018. It was prospective in nature. All the patients were referred from in patient department as cases of clinically symptomatic pleural collections with image-based evidence of loculations or septations. All 30 patients referred for drainage were imaged using suitable imaging technique (USG or CT) to quantise and document presence of septations and loculations in pleural collections. Mean attenuation of pleural fluid, presence of internal echo's and associated pleural thickening (>2mm) was noted. Results: The overall success rate in our study was 77%, with recurrence in 10 % of patients and failure rate of 13 %. The outcome as per etiology was success rate of 100% in parapneumonic effusion, 70 % in TB, 50 % in malignancy and 100% in pleural collection after recent surgical intervention. The common procedure related complications noted in our study were hemothorax (3%), post procedural pain (23 %), pneumothorax (3%). Conclusion: Image guided percutaneous drainage of loculated pleural space collections is an effective and safe procedure.
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REVIEW ARTICLE Top

The N-95 mask: invaluable ally in the battle against the COVID-19 pandemic Highly accessed article p. 323
Zarir F Udwadia, Reyma Sara Raju
DOI:10.4103/lungindia.lungindia_339_20  
The present COVID-19 pandemic, caused by the airborne SARS-CoV-2 virus, has highlighted the vital importance of appropriate personal protective equipment for all exposed health care workers. The single most important part of this armor is the N-95 mask. With the awareness that the virus is spread by both droplets and through the aerosolized route, the N-95 provides protection that a surgical mask cannot match. This timely review looks at the special advantages that an N-95 offers over a surgical mask with specific reference to the COVID-19 epidemic. It also emphasizes the crucial importance of ensuring quality masks with a proper fit. Finally, with acute scarcities of N-95 masks being reported from hospitals globally, it reviews recent literature which attempts to prolong the life of these masks with extended use, reuse and decontamination of used masks.
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CASE REPORTS Top

E-cigarettes: Out of the frying pan into the fire? p. 329
Kavitha Venkatnarayan, Nithin Kumar Reddy Rajamuri, Uma Maheswari Krishnaswamy, Uma Devaraj, Priya Ramachandran, Chitra Veluthat
DOI:10.4103/lungindia.lungindia_11_20  
Electronic nicotine delivery systems were developed over a decade ago to simulate the experience of smoking, although with a lower exposure to toxins than in conventional smoking. However, they have their own unique profile of side effects, some of which can be life threatening. We report the case of a young male, who in a desperate bid to de-addict himself from smoking developed a serious adverse effect related to the e-cigarettes.
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Autopsies are indispensable in the advancement of patient care: Report of an unusual presentation and fatal outcome of an autopsy-diagnosed case of advanced idiopathic interstitial pneumonia p. 333
Evi Abada, Kunil Raval
DOI:10.4103/lungindia.lungindia_570_19  
Idiopathic interstitial pneumonias (IIPs) are a group of fibrosing lung disorders conferring significant morbidity and mortality to patients. Most patients with IIP first present with dyspnea and/or cough. Here, we report the case of a 53-year-old male who presented with severe abdominal pain and weight loss of approximately 100 pounds of 3-month duration. Symptoms of mild dyspnea and cough were obtained during additional history taking. Physical examination and computed tomography of the chest were suggestive of pneumonia, and he was placed on multiple antibiotics but developed worsening respiration that necessitated hyperbaric oxygen and died after 10 days. Histopathological examination of autopsy lung specimen, revealed severe lung damage secondary to a mixed IIP pattern of diffuse alveolar damage, superimposed on extensive interstitial fibrosis, with features of honeycombing, consistent with advanced interstitial/end-stage lung disease. This case typifies an unusual and fatal presentation of IIP, which may be useful in clinical practice.
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Bronchoscopic lung cryobiopsy for the diagnosis of pulmonary alveolar proteinosis in a hypoxemic patient p. 336
Vikas Marwah, C D S Katoch, P Sengupta, Saikat Bhattacharjee
DOI:10.4103/lungindia.lungindia_384_19  
Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by the intra-alveolar accumulation of surfactant due to macrophage dysfunction or the production of abnormal surfactant. Diagnosis is usually confirmed by lung biopsy either bronchoscopically or by video-assisted thoracoscopic surgery. Bronchoscopic lung cryobiopsy (BLC) is increasingly being utilized for the histopathological diagnosis of diffuse parenchymal lung diseases; however, it has rarely been reported for PAP. We report a case of 59-year-old male who presented to our center with gradually worsening breathlessness and cough of 1-year duration. Chest radiograph revealed bilateral extensive pulmonary infiltrates and high-resolution computerized tomography scan revealed extensive bilateral ground-glass opacities with areas of sparing. BAL and transbronchial lung biopsy failed to confirm the diagnosis; hence, BLC was done which revealed pathologic findings suggesting PAP. BLC appears to be a promising diagnostic tool for the diagnosis of PAP and offers several diagnostic advantages compared to conventional techniques.
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CASE LETTERS Top

Pertussis: Re-emergence or underdiagnosed? p. 340
Ujjwayini Ray, Soma Dutta
DOI:10.4103/lungindia.lungindia_500_19  
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Diffuse alveolar hemorrhage due to Plasmodium vivax malaria p. 342
Anshuman Srivastava, Sahithi Avva, Priya Bansal, Ramesh Aggarwal, Shubhalaxmi Margekar, Rajinder Kumar Dhamija
DOI:10.4103/lungindia.lungindia_389_19  
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Pleural lipomatosis: A rare cause of pleural effusion p. 344
Saurabh Karmakar, Somnath Bhattacharya, Somesh Thakur, Deependra Kumar Rai
DOI:10.4103/lungindia.lungindia_517_19  
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A case of large unilateral pneumonia as the presenting feature of systemic lupus erythematosus p. 346
Manoj Kumar Goel, Ajay Kumar, Gargi Maitra
DOI:10.4103/lungindia.lungindia_491_19  
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RESEARCH LETTERS Top

Chest computed tomography in recovered and discharged COVID-19 patients p. 349
Michele Scialpi, Irene Piscioli
DOI:10.4103/lungindia.lungindia_235_20  
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Lung nodule management practice patterns – A survey of Indian physicians p. 350
Vishisht Mehta, Priyanka Makkar, Karishma Bhatia, Sanjeev Mehta, Suhail Raoof
DOI:10.4103/lungindia.lungindia_41_20  
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LETTER TO EDITOR Top

Angiotensin-converting enzyme inhibitors and angiotensin receptor blocker in coronavirus disease 2019: Safe and possibly beneficial p. 352
Nitesh Gupta, Pranav Ish, Sourabh Agstam
DOI:10.4103/lungindia.lungindia_237_20  
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CORRESPONDENCE Top

Medical thoracoscopic cryoevacuation: A novel technique to manage retained hemothorax p. 354
Madhu Sudan Barthwal, Tushar Sahasrabudhe
DOI:10.4103/lungindia.lungindia_364_19  
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Medication adherence in pediatric asthma p. 355
Prawin Kumar, Jagdish Prasad Goyal
DOI:10.4103/lungindia.lungindia_516_19  
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OBITUARY Top

Jitendra Nath Pande (14.06.1941 -23.05.2020) p. 357
Gopi C Khilnani
DOI:10.4103/lungindia.lungindia_502_20  
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GUIDELINES Top

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP) Highly accessed article p. 359
Sheetu Singh, Bharat Bhushan Sharma, Mohan Bairwa, Dipti Gothi, Unnati Desai, Jyotsna M Joshi, Deepak Talwar, Abhijeet Singh, Raja Dhar, Ambika Sharma, Bineet Ahluwalia, Daya K Mangal, Nirmal K Jain, Khushboo Pilania, Vijay Hadda, Parvaiz A Koul, Shanti Kumar Luhadia, Rajesh Swarnkar, Shailender Nath Gaur, Aloke G Ghoshal, Amita Nene, Arpita Jindal, Bhavin Jankharia, Chetambath Ravindran, Dhruv Choudhary, Digambar Behera, DJ Christopher, Gopi C Khilnani, Jai Kumar Samaria, Harpreet Singh, Krishna Bihari Gupta, Manju Pilania, Manohar L Gupta, Narayan Misra, Nishtha Singh, Prahlad R Gupta, Prashant N Chhajed, Raj Kumar, Rajesh Chawla, Rajendra K Jenaw, Rakesh Chawla, Randeep Guleria, Ritesh Agarwal, R Narsimhan, Sandeep Katiyar, Sanjeev Mehta, Sahajal Dhooria, Sushmita R Chowdhury, Surinder K Jindal, Subodh K Katiyar, Sudhir Chaudhri, Neeraj Gupta, Sunita Singh, Surya Kant, Zarir Udwadia, Virendra Singh, Ganesh Raghu
DOI:10.4103/lungindia.lungindia_275_20  
Background: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. Methods: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. Results: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. Conclusion: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.
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