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Year : 2013  |  Volume : 30  |  Issue : 5  |  Page : 17-43  

Abstracts for Poster Presentation

Date of Web Publication11-Nov-2013

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How to cite this article:
. Abstracts for Poster Presentation. Lung India 2013;30, Suppl S1:17-43

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. Abstracts for Poster Presentation. Lung India [serial online] 2013 [cited 2020 Oct 24];30, Suppl S1:17-43. Available from: https://www.lungindia.com/text.asp?2013/30/5/17/121189

Original Articles


Profile of multi and extensively drug-resistant tuberculosis patients attending chest hospital medical college, Kanpur

D. Senthil, Sudhir Chaudhri, Anand Kumar, Sanjay Verma, Avdhesh Kumar

Department of Tuberculosis and Respiratory Diseases, G.S.V.M. Medical Collage, Kanpur, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Multidrug resistant tuberculosis (MDR) has become a significant public health problem in a number of countries and an obstacle to effective TB control.

Aim: To study the profile of MDR patients taking treatment at G.S.V.M. Medical College, Kanpur.

Materials and Methods: MDR suspects were subjected to clinical history, drug-o-gram and examination. Before the start of programmatic management of drug resistant tuberculosis (PMDT) in our hospital sputum of 14 patients of pulmonary tuberculosis and pus of one patient of extra-pulmonary tuberculosis were sent to SRL Religare Lab Mumbai. After the start of PMDT program the sputum samples of remaining 47 patients were sent to intermediate reference laboratory (IRL) Lucknow, Uttar Pradesh. The patients were evaluated and treated by Chennai consensus guidelines 2007 before start of PMDT program after which treatment was given as per program guidelines.

In pre-PMDT program period out of samples of 15 patients 11 turned out to be MDR, two were culture negative. After start of PMDT services out of 47 suspects, 46 turned out be MDR (42 resistant to rifampicin and isoniazid, 4 rifampicin resistant and isoniazid sensitive results with line probe assay were obtained). Their treatment was started according to PMDT program. All patients were human immunodeficiency virus seronegative and 4 had diabetes mellitus.

Majority of drug resistant suspects turned out to be MDR.

A comparative study of adverse drug events related to intermittent and daily regimens of anti-tubercular therapy

Goli Vedavyas, Aneena Suresh, R. Karthikeyan, G. Sathyaprabha

Department of Pharmacy, P.S.G. College of Pharmacy, Coimbatore, Tamil Nadu, India. E-mail: [email protected]

Background: Though efficacy of daily and intermittent regimens of anti-tubercular treatment (ATT) is proven to be comparable, their tolerance by patients is debated which requires further evaluation. We aimed at comparing tolerance of ATT in terms of adverse drug events (AE) of both ATT regimens and evaluate their clinical predictors.

Materials and Methods:
Seventy eight subjects (44 on intermittent and 34 on daily regimens) on ATT, for duration between 2 weeks to 2 months, were interviewed with review of medical records. Any new or worsening of existing symptoms lasting for at least 2 days during ATT intake was defined as AE and grouped according to the system or organ involved.

Incidence of gastrointestinal, neuromuscular, neuropsychiatric, skin, eye and ear-nose-throat related AE were 75.6%, 53.8%, 50%, 29.5%, 3.8% and 33.3%, respectively among the study population which were self-limiting by 1 week in the majority. There was no difference in incidence of AE between intermittent and daily regimens. Prescribing proton pump inhibitors for subjects did not prevent incidence of gastrointestinal AE. Similarly pyridoxine at 20 mg/day did not prevent neuromuscular or neuropsychiatric AE. Skin AE was significantly common among subjects of low socioeconomic strata (odds ratio 4.97, 95% CI = 0.03-0.89, adjusted for age, gender, duration and type of ATT regimen).

This study found a high incidence of ATT induced self-limiting AE which was not different between both the regimens. Routine use of proton pump inhibitors and pyridoxine did not improve tolerance. Skin related AE was common among subjects in low socioeconomic strata.

Factors influencing development of drug resistance among multi drug-resistant tuberculosis patients attending PMDT site at Ajmer

Rakesh C. Gupta, Kamendra Singh Pawar, Neeraj Gupta, Ramakant Dixit, Rajveer Kuldip

Department of Respiratory Medicine, J.L.N.M.C, Ajmer, Rajasthan, India. E-mail: [email protected]

The prevalence of multi drug-resistant tuberculosis (MDR-TB) mirrors the functional state and efficacy of tuberculosis control. It is crucial to recognize the factors responsible for drug resistance in order to develop the most appropriate case finding strategies.

To identify risk factors for development of drug-resistance in MDR-TB.

Materials and Methods:
It was a hospital based observational study. All 288 cases diagnosed as MDR-TB from 1 st January 2012-31 st December 2012, admitted at programmatic management of drug resistant tuberculosis site, Ajmer were included. Personal interview of each of study subject was done. The questionnaire covered different aspects of development of drug resistance, i.e., patient related, drug related and health care related factors. Proforma contained questions on previous antitubercular treatment (ATT) including treatment card, drug-o-gram and side effects, adequacy of doses, combinations, addition of streptomycin in re-treatment, quinolones before drug susceptibility test (DST), empirical second line ATT without DST, duration of treatment and clinical outcome.

The previous ATT was there in 98.95%, of them 57.19% received ATT from revised national tuberculosis control program (RNTCP) while 36.49% received ATT by both private and RNTCP. About 39.29% patients were defaulters and the most common reason for default was improved symptoms. Inadequate drug dosage and combinations were found in 17.89% and 21.05%, respectively and wrong categorization of ATT under RNTCP was found in 11.22%. History of contact of MDR-TB was found in 2.77% while 22.91% were contacts of pulmonary tuberculosis.

The risk factors of drug resistance in our study were found to be a complex web of patient related, drug related and health care related factors.

Diagnostic yield of mycobacterial deoxyribonucleic acid in pleural fluid from patients with suspected pleurisy by polymerase chain reaction

C. G. Mohandas, E. Jyothi, Sunny George, P. T. James

Deparment of Chest Diseases, Government Medical College, Calicut, Kerala, India. E-mail: [email protected]

Background: Tuberculous pleurisy is the second most common form of tuberculosis in endemic areas. A definitive diagnosis of tuberculous pleurisy requires mycobacterial culture of pleural fluid or pleural biopsy.

To provide updated information about the diagnostic yield of tuberculosis polymerase chain reaction (TB-PCR) in diagnosing tuberculous pleural effusion.

Materials and Methods: A total of 20 patients admitted to wards and IRCU in I.C.D. Medical College, Kozhikode were included in a cross sectional study.

Analysis of the data revealed following results. Pleural fluid acid fast bacilli BACTEC culture yielded positive results in 6 patients (30%) and TB-PCR yielded positive results in13 patients (65%). One patient yielded positive sputum culture (5%). No definitive diagnosis could be made in 1 case (5%).

TB-PCR could be used as a diagnostic test for detecting tuberculous pleural effusion. TB-PCR yielded higher positive results compared to pleural fluid culture alone. Combined TB-PCR, pleural fluid culture and sputum culture yielded highest positive results.

Outcome of dots retreatment regimen (Cat II) in patient with isoniazid resistant tuberculosis

Nitin Jain, M. J. Qureshi, N. K. Jain

Department of Respiratory Medicine, Institute of Respiratory Disease, SMS Medical College, Jaipur, Rajasthan, India. E-mail:[email protected]

Background: Isoniazid resistance is an important aspect of management of tuberculosis but it still remains under investigated. The present study was planned to assess outcome of patients with isoniazid resistant tuberculosis when put on retreatment category II (CAT II) regimen (2SHREZ/1HREZ/5HRE) and amplification of drug resistance if any.

Materials and Methods:
234 sputum positive re-treatment patients were subjected to initial mycobacterial culture and drug susceptibility test (DST) before putting on re-treatment CAT II regimen, from which 37 were isoniazid resistant. These patients were put on CAT II and the results were analysed.

Results: Out of these 234 sputum positive re-treatment patients 40.6% were pan sensitive, 19.23% were mono and poly drug-resistant, 17.94% had multi drug-resistant (MDR), 13.67% were culture negative and 8.54% were contaminated. Among the mono and poly-drug-resistant tuberculosis, isoniazid resistance was present in 15.81%. Most of patients (51.1%) had history of 2 spells of antitubercular treatment (ATT), another 28.8% had 1 spell of ATT and 20% had ≥ 3 spells of ATT. A poor outcome was present with history of ≥ 3 spells of ATT. Re-treatment patient in relapse group had better outcome and those in failure group had worst outcome followed by treatment after default (TAD) patients. Among 37 isoniazid (INH) resistant patient amplification was observed in 6 (16.2%) patients and 5(13.5%) patients had no-amplification. Among 37 Patients of INH resistance, 48.6% patients were cured, 29.9% patients were failure, 16.2% patients died and 5.4% patients were defaulter.

INH resistance is common in re-treatment cases and DST should be performed before putting on re-treatment.

Short course chemotherapy for skeletal tuberculosis

Bhupendra Vala, Amit Patel, Jigna Dave

Department of TB and Respiratory Disease, Government Medical College, Sir T General Hospital, Bhavnagar, Gujarat, India. E-mail: [email protected]

Tuberculosis (TB) is highly endemic in India. The prevalence of extra-pulmonary forms of TB; e.g, skeletal TB; is also high. Skeletal TB poses a diagnostic challenge to clinicians.

To study clinical and radiological improvement in patients of skeletal TB who completed short course chemotherapy (SCC) under revised national tuberculosis control program (RNTCP).

and Methods: It was a single center and cross sectional study at outpatient department of a tertiary care hospital. 50 patients of skeletal tuberculosis were enrolled. History and clinical profile were studied. Radiological profile was studied using magnetic resonance imaging scan, ultrasonography and X-rays of involved bones and joints.

and Discussion: Of these 50 patients, 44 (88%) completing SCC were analyzed. 6 were lost on follow-up. 40 patients were put on category I antitubercular treatment (ATT) and 4 on category II ATT under RNTCP. 28(64%) had spinal tuberculosis, 16(36%) had peripheral skeletal tuberculosis involving knee joint (10), hip joint (4), femur (1) and humerus (1). On completion of ATT, 91% improved clinically. Radiological improvement was seen in 84% (37/40) who showed clinical improvement. 91% patients improved who took category I ATT and 75% patients improved who took category II ATT. Rest 16% (7/44) patients didn't improve radiologically.

SCC is as efficacious in skeletal TB as in pulmonary TB. Radiological improvement may not be present on completion of ATT. Clinical features should be considered as criteria for improvement.

Atypical mycobacteriosis in a tertiary care hospital in Mumbai

Amit Panjwani, Shashikala Shivaprakash

Department of Pulmonary Medicine, Seven Hills Hospital Marol, Andheri (East), Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Atypical or non-tuberculous mycobacteria (NTM) are ubiquitous in environment. In India, M. tuberculosis infection has always overshadowed true prevalence of NTM. Although the exact magnitude of NTM is difficult to predict, it varies from 1% to 28%.

The present report describes cases of NTM related diseases detected and treated in a tertiary care hospital in Mumbai.

Materials and Methods:
18 cases of NTM related diseases were diagnosed over a period of 20 months from Jan 2011 to Aug 2013 in a tertiary care hospital in Mumbai. Of these 18 cases, species identification was possible in 9 cases. A retrospective analysis of the medical records of these 9 consecutive cases of NTM was conducted. Demography, clinical and radiological presentations, species isolated, antimicrobial therapy instituted and outcome of these patients evaluated.

Results and Discussion:
Patients were predominantly females (75%) with age range of 23-66 years and mean age of 38.7 years. Four of these cases had known underlying illness including diabetes, alcoholism, cancer, structural lung disease like fibrosis and bronchiectasis. Infection involved lungs (5 cases), musculo-skeletal (2 cases), lymph nodes (1 case) and sub-cutaneous tissue (1 case). Mycobacterium avium Scientific Name Search  complex, Mycobacterium fortuitum, Mycobacterium gordonae were isolated in 2 cases each while Mycobacterium kansasii, Mycobacterium simiae, Mycobacterium abscessus were isolated in others. Good therapeutic response was observed in all the cases treated with anti-microbial agents. Three cases required additional surgical procedures.

This series highlights the importance of NTM infections and there is a serious need for increased awareness to look for these infections in our country.

To study the profile of drug resistant tuberculosis in Dr. Rajendra Prasad government medical college, Kangra, Tanda (Himachal Pradesh)

Rekha Bansal, Parveen Kumar Sharma

Department of Pulmonary Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India. E-mail: [email protected]

Introduction: Since the registration of first drug resistant tuberculosis patient on 22 nd March 2011 in Dr. Rajendra Prasad Government Medical College, Kangra at Tanda DOTS-plus site, 232 patients have been initiated on category IV anti-tubercular regimen. We present the profile of first 94 patients registered from March 2011 to October 2012.

To study the profile of drug resistant tuberculosis in Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (Himachal Pradesh).

and Methods: For a retrospective study, case records of all patients registered for treatment of drug resistant tuberculosis under revised national tuberculosis control program-programmatic management of drug-resistant TB from March, 2011 to October, 2012 were screened as per proforma approved by institutional ethical committee.

and Discussion: Out of 94 patients (mean age 40.27 ± 15.06, 68 (72.34%) were males and 26 (27.66%) were females with an average age of 44.21 ± 14.29 in males and 29.96 ± 11.99 in females. Patients belonged to six districts of Himachal Pradesh with maximum 38% from Kangra and 29% from Mandi. Category II antitubercular treatment was taken for an average of 47.17 ± 26.15 weeks with one or more of the following outcomes: Failure - 44.68%, cured - 25.53%, default - 4.26% and cured twice - 3.19%. GeneXpert test was done in 25 patients (26.6%). Out of 79 patients in whom culture and drug susceptibility test was done the resistance pattern was: Resistance to rifampicin - 100%, resistance to isoniazid - 88.41%, resistance to streptomycin - 69.62%, resistance to ethambutol - 39.24% and resistance to RHES - 32.91%. 77.22% were found multi drug-resistant tuberculosis (MDR) cases.

MDR tuberculosis is a serious problem in Himachal Pradesh.

To study the culture conversion, default rate and extensively drug-resistant suspects in category IV patient in a D.R. TB Centre

Santosh Kumar, Gajendra Vikram Singh, Rehbar Khan, Devendra Kumar, Rajesh Kumar Gupta, Dilip Singh Rajoria

Department of Tuberculosis and Chest Diseases, S.N. Medical College, Agra, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Multi-drug resistant tuberculosis (MDR-TB) is an increasing health problem in India. According to World Health Organization, the estimated cases of MDR-TB in India are 1-3% in new cases and 12% in retreatment cases. India houses one fifth of the world's drug-resistant tuberculosis cases, with prevalence and incidence 249 and181 per 100,000 population, respectively.

To study the culture conversion, extensively drug-resistant tuberculosis (XDR-TB) suspects, factors favoring culture conversion and factors responsible for adverse outcome and side effect of second line antitubercular treatment (ATT).

and Methods: Study comprised of patients who were diagnosed MDR by culture and drug susceptibility test method from revised national tuberculosis control programme (RNTCP) accredited lab and initiated category-IV treatment in D.R.TB Centre, Department of Tuberculosis and Chest Diseases, S.N. Medical College, Agra. Detailed history and preclinical evaluation as per guidelines were done and at the end of 3 rd 4 th 5 th and 6 th month sputum samples were sent for acid fast bacilli staining and culture. Various factor responsible for adverse outcome and good outcome were evaluated in detail.

and Discussion: Out of 109 MDR-TB patient put on category-IV, culture conversion at 3 rd month was in 52 (47.70%), at 4 th month was in 58 (53.21%) and at 5 th month was in 66 (60.55%). 11patients (10.09%) expired, 7 (6.42%) defaulted and 12 (11.01%) were suspected XDR.

Conclusion: MDR-TB is major health problem worldwide. Due to less efficacy and more side effect of second line ATT, longer duration of treatment, MDR-TB is difficult to treat even with free supply of ATT through DOTS-PLUS.

Survey on the knowledge, attitudes and practices on tuberculosis among health-care workers in AVBR Hospital, Sawangi (Meghe)

Pritpal Singh Hans, Babaji Ghewade, Satyadeo Choubey

Department of Pulmonary Medicine, Datta Meghe Institute of Medical Sciences (Deemed University), AVBR Hospital, Sawangi (Meghe), Wardha, Maharashtra, India. E-mail: [email protected]

Introduction: Tuberculosis (TB) is a communicable disease requiring prolonged treatment and poor adherence to a prescribed treatment increases the risk of morbidity, mortality and spread of disease in the community. The World Health Organization declared TB as a global public health emergency in 1993 and since then intensified its efforts to control the disease worldwide.

To investigate the knowledge, attitudes and practices (KAP) of medical faculty for tuberculosis at AVBRH.

Materials and Methods:
It was hospital based observational study. The study was conducted in AVBRH and JNMC, Sawangi (M), Wardha and included 100 paramedical staff through non-probability convenient sampling.

Suboptimal performance on TB-related knowledge, attitudes and practices was found among the survey participants. Less than 40% of respondents had good knowledge of TB. Significant associations with good knowledge were only found with highest educational level obtained and the number of years employed to a public health facility.

Health care workers should be included as a target group for activities to increase competence in TB management and compliance with national guidelines. Interventions should address a combination of the varying influences on behavior, focusing on specific gaps identified to improve their impact.

Pulmonary impairment in treated pulmonary tuberculosis

Dhipu Mathew, Srinivasan, Aruna Shanmuganathan, Thilagavathy

Department of TB and Chest, Meenakshi Medical College Hospital and Research Institute, Kanchipuram, Tamil Nadu, India. E-mail: [email protected]

Background: Pulmonary tuberculosis can cause parenchymal destruction by up-regulation of several proteases and dysregulation of protease control. So, pulmonary tuberculosis resolves with residual lesions in form of fibrosis, bronchiectasis and rarely bronchial stenosis, all of which can cause pulmonary function impairment. This study was undertaken to assess the pulmonary function impairment in treated pulmonary tuberculosis patients.

Materials and Methods:
In this retrospective observational study, a total of 40 treated pulmonary tuberculosis patients were taken. Clinical data and chest X-ray pattern were recorded. Their pulmonary function was assessed using spirometry.

Results: All patients were symptomatic and most common symptom was breathlessness. Unilateral lung involvement was seen in 21 patients and bilateral lung involvement in 19. 23 (57.5%) patients showed a mixed pattern in spirometry, 8 (20%) showed an obstructive pattern, 5 (12.5%) showed restrictive pattern and rest 4 were normal.

The most common pulmonary impairment pattern in treated pulmonary tuberculosis patients was mixed. Hence pulmonary tuberculosis patients need follow-up even after treatment for early detection and treatment for their pulmonary disability.

Incidence of multi drug resistant tuberculosis among re-treatment cases in a tertiary care hospital

K. Maheswaran, R. Sridhar, O. R. Krishnarajasekhar, C. Chandrasekar

Department of T.B. and Respiratory Diseases, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Multidrug-resistant tuberculosis (MDR-TB) threatens to become the dominant form of tuberculosis in many parts of the world because of decades of inappropriate treatment coupled with poor adherence. Infection with MDR-TB is associated with poor outcomes because of delays in treatment, the need for long medication regimens and toxicity of the drugs.

To know the trends of MDR-TB among those who were started on category II anti-tubercular treatment in tertiary care hospital (Government hospital of thoracic medicine Tambaram sanatorium).

Materials and Methods:
We did line probe assay in sputum samples of those patients.

Among 3339 patients, 283 were diagnosed as MDR-TB.

Conclusion: MDR-TB is becoming a dominant form of tuberculosis in many parts of India.

Role of induced sputum in diagnosis of pulmonary tuberculosis

Palvai Rajesh Kumar, Rameshwara Kumar Mosali, Raju Ch, A. Sathya Prasad

Department of Pulmonary Medicine, Mamata General Hospital, Khammam, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Detection of smear-positive pulmonary tuberculosis cases is vital for tuberculosis control. Sputum microscopy is a highly specific test, a low-cost and appropriate technology. Diagnosing pulmonary tuberculosis is challenging in patients with clinicoradiological picture suggestive of pulmonary tuberculosis and unable to produce adequate expectoration. The role of sputum induction to overcome this problem is tested in this study.

To assess the value of sputum induction with 3% hypertonic saline nebulization as a diagnostic tool in patients with suspected pulmonary tuberculosis who have inadequate sputum or have a sputum smear negative for acid fast bacillus (AFB).

and Methods: 50 patients with clinical and radiological findings suggestive of pulmonary tuberculosis with inadequate sputum or smear negative with spontaneous sputum were studied. In those patients, sputum was induced with 20 ml of 3% hypertonic saline delivered through ultrasonic nebulizer. The specimens were subjected to Ziehl Neelsen staining and were examined under oil immersion lens for AFB.

40 patients (80%) could produce adequate sputum after sputum induction. Sputum samples from 20 patients were found to be positive for AFB on smear examination. Out of the remaining 30 patients, 8 patients were diagnosed to be pulmonary tuberculosis and 4 patients were diagnosed to be bronchogenic carcinoma on further evaluation.

Sputum induction is safe, cheap and effective procedure for microbiological confirmation of pulmonary tuberculosis in patients who have inadequate sputum or have a sputum smear negative for AFB.

A comparative study of patients' perception of intermittent and daily regimens of antitubercular treatment

Mounika Godavarthi, Lakshmi Prasanna Marise, R. Karthikeyan, G. Sathyaprabha

Department of Pharmacy Practice, PSG College of Pharmacy, Coimbatore, India. E-mail: [email protected]

Background: Though both intermittent and daily regimens of anti-tubercular treatment (ATT) have comparable efficacy, patients' perception towards the treatment may vary. This behavioral factor is an important determinant for treatment compliance and success rate.

We aimed at finding out predictors and comparing patients' perception on both the ATT regimens.

Materials and Methods:
Seventy eight subjects (44 in intermittent and 34 on daily regimen) on ATT with duration between 2 weeks and 2 months were interviewed and their medical records reviewed. Subjects' attitude towards treatment adherence (TA) and their satisfaction with treatment (TS) were assessed with 4-item questionnaires derived and validated from treatment satisfaction questionnaire for medication. Good TA and TS were defined with scores 0/4 and 4/4 respectively.

Predictors of good TA were absence of co-morbid illness (odds ratio 2.95, 95% confidence interval [CI] = 1.10-7.70) and absence of neuropsychiatric adverse drug events (odds ratio 2.86, 95% CI = 1.14-7.16). There was no significant difference in attitude towards treatment adherence between subjects in intermittent and daily regimens. Good TS was associated with subjects belonging to higher socioeconomic strata (odds ratio 2.29, 95% CI = 1.13-7.55) and those taking daily regimen ATT (odds ratio 0.36, 95% CI = 0.14-0.93). All predictors were adjusted for age, gender, duration of illness and duration of ATT.

Conclusion: This study found important predictors of patients' behavior in terms of treatment satisfaction and adherence and attitude towards adherence. These predictors may be useful in evolving strategies to improve treatment compliance.

The role of QuantiFERON TB Gold in diagnosis of suspected cases of tuberculosis

K. Anand Babu, R. Narasimhan, R. P. Ilangho, Manish Kumar Sharma

Department of Respiratory Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: The QuantiFERON TB Gold (QFT) method has been validated as a contributory investigation for the diagnosis of latent tubercular infection. However, the use of this method as a diagnostic test for active tuberculosis (TB) in countries with high prevalence of tubercular infection is still unclear.

Aim: The aim of this study was to evaluate the role of QFT in diagnosis of suspected cases of TB.

Materials and Methods:
We did a prospective study, including 54 patients with clinico-radiological suspicion of TB (both pulmonary and extrapulmonary TB). QFT test was done on the same day followed by the relevant investigations (culture of sputum/ bronchoalveolar lavage, pleural biopsy, endobronchial ultrasound/transbronchial needle aspiration) for making the definitive diagnosis of TB. All patients had negative serology for Human immunodeficiency virus.

Of the 54 patients, active TB was diagnosed in 23 (43%) out of which pulmonary and extrapulmonary TB (EPTB) cases were 11 (48%) and 12 (52%), respectively. The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value, positive likelihood ratio (LR+), negative likelihood ratio (LR-) of QFT were 61% (95% confidence interval [CI] = 39-80%), 87% (95% CI = 69-96%), 78% (95% CI = 52-93%) and 75% (95% CI = 52-93%),4.72 (95% CI = 0.44-1.83) and 0.45 (95% CI = 0.27-0.76), respectively. Interestingly, all EPTB patients showed QFT positive.

The low sensitivity of QFT assay shows that it should not be used in isolation to exclude the diagnosis of active TB. However, the high specificity and PPV of the test denotes that in high endemic countries like India, it has a potential role in diagnosis of active tuberculosis in addition to other definitive methods, especially in EPTB.

Study of profile of pulmonary tuberculosis with diabetes mellitus and serum vitamin-D levels

Raunak Das, Jyoti Patnaik, Hemanta Kumar Sethy, Thitta Mohanty, Geetanjali Panda, Manoranjan Dash, Nrusingha Charan Dash, Anuradha Bheri

Department of Pulmonary Medicine, S.C.B. Medical College, Cuttack, Odisha, India. E-mail: [email protected]

Introduction: The link between diabetes mellitus (DM) and tuberculosis (TB) has been recognized for centuries and there is strong association of vitamin-D concentrations with TB and DM.

and Objectives: (1) to study clinico-radiological profile of patients of pulmonary TB with DM and (2) to correlate vitamin-D levels between these patients and normal people.

and Methods: This study was conducted in TB ward of PG department of Pulmonary Medicine, S.C.B.M.C.H. Cuttack, between September 2010 and August 2012. The study included 55 cases of pulmonary TB (diagnosed either by positive sputum microscopy or by clinical and radiological grounds when sputum microscopy was negative), with DM and 32 normal people (vitamin D estimation in both groups).

The study showed 45.45% patients were underweight. Cough and crepitations were present in 90.9% and 55.55% patients, respectively. There were cavitation in 45.47% patients and multiple zone involvement in 50.91% patients. Average vitamin-D levels in cases were 16.71 ng/ml and 31.97 ng/ml in normal people. Furthermore, the study showed decrease in vitamin-D levels in patients of PTB with DM in comparison with normal people with respect to age and BMI.

Diabetes mellitus is an important risk factor for TB and affects disease presentation and treatment response. Tuberculosis might induce glucose intolerance and worsen glycemic control in people with diabetes. Vitamin-D also plays a vital role in patients of tuberculosis.

Comparison of same day sputum microscopy with 2 days microscopy in the diagnosis of tuberculosis

Lisha Madhavan, Davis Paul, V. Dinesa Prabhu, K. P. Venugopal

Department of Pulmonary Medicine, Government Medical College, Kottayam, Kerala, India. E-mail: [email protected]

Introduction: Direct sputum smear microscopy is the most widely used test for the diagnosis of pulmonary tuberculosis. It is highly specific but associated with considerable patient inconvenience as they have to come to the hospital at least for 2 days for diagnosis.

To compare same day sputum smear microscopy with 2 days sputum smear microscopy in terms of diagnostic accuracy.

and Methods: 396 patients with signs and symptoms suggestive of pulmonary tuberculosis were sent for sputum examination. Two sputum samples were collected from them on day 1 and numbered as sample I A and I B. On 2 nd day another morning sample was collected and numbered as sample II. The yield of serial samples and 2 days samples were compared.

and Discussion: A total of 75 patients were detected as smear positive by the 2 days method. All those 75 patients were detected positive with the same day method. Statistical analysis was done using Chi-square test considering a significant P < 0.05.

Same day sputum smear microscopy carries the same diagnostic efficacy as two day smear microscopy for the detection of active pulmonary tuberculosis. It may be more convenient and cost-effective to the patient as well as to the health care system because it reduces the number of hospital visits and may help to improve patient compliance.

Tuberculosis in human immunodeficiency virus: Correlation of CD4 with radiological presentation and tuberculin test

Pantham Sunitha, M. Sravan Kumar, M. G. Krishna Murthy, D. Dhanalakshmi

Department of Pulmonary Medicine, Kakatiya Medical College, Warangal, Andhra Pradesh, India. E-mail: [email protected]

Introduction: According to World Health Organization (WHO), tuberculosis is currently spreading at the rate of one person per second. Tuberculosis occurs earlier in the course of Human immunodeficiency virus (HIV) infection than many other opportunistic infections. HIV also promotes both the progression of latent tuberculosis infection to active disease and relapse of the disease in previously treated patient.

Aim: (1) to study the mode of radiological presentation of pulmonary tuberculosis with varying CD4 count, so as to provide an empirical approach for early diagnosis and treatment of tuberculosis in HIV patients and (2) to study the response to PPD in tuberculosis patients with HIV at different levels of immunosuppression.

and Methods: After inclusion into the study, consent of the patient, detailed history and thorough physical examination were done; patients were subjected to sputum for acid fast bacilli, tuberculin test, CD4 count, chest X-ray. Additional investigations were done if strongly indicated.

In this study conducted on 100 patients, majority of patients with CD4 <200 cells/cumm were associated with atypical radiographic pattern and the patients with CD4 >200 cells/cumm were associated with typical radiographic pattern. The positive PPD test helped to clinch the diagnosis.

Therefore in our country where the prevalence of tuberculosis is high, we should have a high index of suspicion for tuberculosis in patients who are HIV positive especially with CD4 count <200 cells/cumm with atypical X-ray presentation.


Comparison of efficacy of microbiological yield in bronchoscopic and non-bronchoscopic alveolar lavage in mechanically ventilated patients

Abdul Majeed Arshad, Patricia Infanta, M. Sangeetha, B. Hari Prasad

Intensive Care Unit, Sri Ramachandra University, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Patients in intensive care unit face fatal consequences not only due to their primary critical illness but also due to the hospital acquired infections, which increase the number of ventilator days and mortality rates.

The present study compared the microbiological outcomes from bronchoscopic bronchoalveolar lavage (BAL) and non-bronchoscopic bronchoalveolar lavage (NBAL) specimens.

and Methods: After obtaining informed consent from the relatives of 50 mechanically intubated patients in the intensive care unit of Sri Ramachandra University (from August 2012 to January 2013), BAL and NBAL specimens were collected by flexible bronchoscope and double catheter techniques, respectively. Details like age, gender and primary diagnosis on admission were recorded. A minimum of 5 ml sample was collected and sent within 1 h for microbiological analysis.

and Discussion: In this study, 35 (70%) of the participants were males and 15 (30%) were females. Using NBAL, 37 (74%) were culture positive and 13 (26%) were culture negative. BAL proved culture positive in 34 (68%) samples and negative in 16 (32%) samples. The organisms that grew in the culture were Klebsiella pneumoniae (48%, BAL - 45.8%, NBAL - 54.2%), Acinetobacter baumannii (46%, BAL - 47.8%, NBAL - 52.2%), Pseudomonas aeruginosa (28%, BAL - 50%, NBAL - 50%),  Escherichia More Details coli (14%, BAL - 57.14%, NBAL - 42.86%) and Staphylococcus aureus (6%, BAL - 33.3%, NBAL - 66.7%). NBAL is relatively inexpensive, requires lesser expertise and useful method for serial evaluation of suspected nosocomial infections in mechanically ventilated patients.

NBAL is as efficacious as BAL in diagnosing ventilator-associated pneumonia.

The impact of a multidimensional infection control approach on the reduction of ventilator-associated pneumonia in intensive care units

Akashdeep Singh, Kanwaldeep Singh Layall, Manpreet Kaur, Deepinder Chhina

Department of Pulmonary and Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: [email protected]

Introduction: Ventilator-associated pneumonia (VAP) is the most serious health care-associated infection.

The aim of this study was to analyze the impact of a multidimensional infection control approach on the reduction of VAP in intensive care units (ICUs).

Materials and Methods: We conducted a before-after study from January 2012 to July 2013, which was divided into baseline (phase 1) and intervention (phase 2) periods. During phase 1, active prospective outcome surveillance of VAP was performed by applying the definitions of the centers for disease control and prevention/national health safety network and the methodology of the International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach was implemented. The components of the multidimensional approach included: Performance of active outcome surveillance for VAP; education regarding epidemiology of VAP, risk-factors and interventions; performance of regular oral care with an antiseptic solution; promotion of adherence to hand-hygiene guidelines; maintenance of patients in a semirecumbent position; feedback of VAP rates; process surveillance; performance feedback of infection control practices. Ventilator-associated pneumonia rates obtained in phases 1 and 2 were compared.

We recorded data from 1757 patients hospitalized in ICUs, for a total of 13177 ICU bed days. The VAP baseline rate was 34.81 per 1000 ventilator-days. During phase 2, the VAP rate significantly decreased to 10.7/1000 ventilator-days.

The implementation of the multidimensional approach significantly reduces the risk of VAP.

A study of ventilator associate pneumonia: Incidence, organism isolated, antibiotic resistance pattern and outcome in intensive care unit

Mirinda Jauhari, Lalit Singh, Anurag Agrawal, Rajeev Tandon, Himanshu Verma

Department of Anaesthesia and Critical Care, Sri Ram Murti Smarak Institute of Medical Sciences, Bhojipura, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Ventilator associate pneumonia ( VAP) is a major cause of hospital morbidity and mortality. The lack of gold-standard diagnostic criteria for diagnosis of VAP leads to either overdiagnosis or underdiagnosis. Both of which are potentially harmful to such patients.

To study the incidence of early onset VAP (48-96 h) vs. late onset VAP (>96 h), organisms isolated in the tracheal aspirate, the antibiotic resistance among the isolated organisms and the probable outcome in the intensive care unit (ICU).

and Methods: A total of 100 patients of either sex in age group of 18-75 years who were on mechanical ventilation for >48 h were randomly selected for the study. The patients who were admitted with pneumonia or developed pneumonia within 48 h, acute respiratory distress syndrome or who died within 48 h of initiation of mechanical ventilation were excluded. The diagnosis of VAP was made on clinical grounds when a score of >/=6 was obtained on modified clinical pulmonary infection scoring system. The data were analyzed and results were tabulated on basis of demographic profile, incidence of VAP (early/late onset), organisms isolated, antibiotic resistance pattern and outcome.

and Conclusion: Incidence of VAP in our ICU was approximately 42%, which is on higher side. Late onset VAP was more common in our ICU and had greater mortality than early onset VAP. The most common organism isolated was klebsiella followed by acinetobacter and pseudomonas. The acinetobacter species is more commonly associated with multi-drug resistance and is associated with greater mortality.


Skin prick reactivity in atopic patients: Data from western India

Aparna Iyer, Lavina Mirchandani, Girija Nair, T. K. Jayalakshmi, Abhay Uppe

Department of Pulmonary Medicine, Padmashree Dr. D. Y. Patil Hospital, Medical College and Research Centre, Mumbai, Maharashtra, India. Email: [email protected]

Background: Trigger factors for allergy vary with local milieu and food habits.

To determine sensitization to allergens in atopic patients in urban western India.

Materials and Methods: Skin prick test was performed in 48 patients with allergic rhinitis, asthma, skin or food allergies at an urban tertiary care hospital in western India. After written informed consent, allergen, positive and negative control solutions were introduced into the epidermis of the volar surface of forearm by sterile hypodermic disposable needles. Results were interpreted after 15 min by comparing wheal and induration to control reactions.

Results: Commonest sensitizing allergens were Aspergillus niger, green pea and housefly (41.6%), followed by green gram (39.5%) and mite (D-farinae-37.5%). 35.4% patients reacted to Penicillium spp, Candida albicans, pigeon feather and egg.

Aspergillus niger, green peas and housefly were the commonest sensitizing allergens.

Prevalence of ABPA in patients of bronchial asthma

Kalpesh Patel, Vishal Chopra, Ashrafjit S. Chahal,

Don Gregory Mascarenhas, Komaldeep Kaur

Department of Pulmonary Medicine, GMC, Patiala, Punjab, India. E-mail: [email protected]

Background and Objective: Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus. The prevalence of ABPA in patients with bronchial asthma remains unknown. Contemporary reports suggest that ABPA occurs in upto 11% of patients with asthma. We had made an attempt to find out the prevalence of ABPA in patients of bronchial asthma using the Rosenberg-Patterson criteria.

Materials and Methods: 50 consecutive asthma patients, who visited our hospital, were subjected to A. fumigatus skin test. Those patients who proved to be skin prick test (SPT) positive for A. fumigatus were further evaluated for ABPA. Eosinophilia was considered if a blood absolute eosinophil count >500 cells/μL.

Results: Among 50 patients, sixteen patients (32%) showed positive response to A. fumigatus in SPT, raised absolute eosinophil count was present in thirteen patients (26%) and elevated serum total IgE levels (>417 IU/ml) was seen in thirteen patients (26%). Elevated serum A. fumigatus specific IgE (>0.35 kUA/l) was seen in twelve patients (24%). 10 patients were subjected to high-resolution computed tomography out of which 9 patients showed bronchiectatic changes. A diagnosis of ABPA was made in 13 patients (26%).

The prevalence of ABPA in patients with bronchial asthma remains unknown. Our study showed prevalence of ABPA to be 26% in patients of asthma with SPT positivity, although the sample size was small. The study is being continued.

Impact of chronic asthma on upper limb and lower limb peripheral sensory nerves functions

Dipti Agarwal, Sushma Sood, Prem Parkash Gupta

Department of Physiology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. E-mail: [email protected]

Aim: To assess the impact of chronic asthma on peripheral sensory nerves functions using electrophysiological analysis and to find out correlation(s) between sensory nerves functions and patients' characteristics especially-forced expiratory volume-first second (FEV 1 ), forced vital capacity (FVC) and peak expiratory flow rate (PEFR).

Materials and Methods: We included 60 stable asthma patients (40 females and 20 males) diagnosed as per Global Initiative for Asthma guidelines. They were structured to two groups: 30 patients with FEV 1 /FVC ratio >70% (group 1) and 30 patients with FEV 1 /FVC ratio ≤70% (group 2). Amplitude, latency and conduction velocity of three sensory nerves (median nerve, ulnar nerve and sural nerves) were assessed.

There was no significant difference between two groups regarding age (28.47 ± 9.24 year vs. 29.67 ± 4.66 year; P = 0.528) and height (P = 0.738). Patients in group 2 had significantly prolonged duration of illness (11.23 ± 3.32 year vs. 5.57 ± 3.18 year), lower FEV 1 (2.130 ± 0.381 L vs. 2.856 ± 0.427 L) and lower PEFR (4.879 ± 0.576 L/s vs. 5.988 ± 0.820 L/s). Conduction velocities of all sensory nerves were significantly reduced and latencies of ulnar and sural sensory response were significantly increased in group 2. There was no significant difference between groups regarding amplitude of response of the tested nerve. Duration of illness, FEV 1 and PEFR had significant correlations with sensory nerves variables.

Conclusion: Severe asthma group patients had increase in latencies and decrease in conduction velocity of peripheral sensory nerves; nerve dysfunctions were having correlations with duration of illness, FEV 1 and PEFR.

Analysis of allergen sensitivity in bronchial asthma

Zareen Mohamed, Usha Shukla, Sathiya

Allergy and Asthma Clinic, Dr. Mehta's Hospitals Pvt. Ltd., Chennai, Tamil Nadu. E-mail: [email protected]

Aim: To study allergen sensitivity in patients of bronchial asthma attending an allergy and asthma clinic.

and Methods: 1200 skin prick tests were performed with a standard panel of 40 allergens in 30 patients diagnosed as bronchial asthma based on Global Initiative for Asthma guidelines, between January 2013 to August 2013 in the allergy and asthma clinic at Dr. Mehta's Hospitals Pvt. Ltd. Patients in the age group of 10-40 years were included in the study. Pregnant asthmatics and patients above the age of 40 years were excluded. Allergen extract included species of dust-mite (Dermatophagoides pteronyssinus and Dermatophagoides farinae), molds (Aspergillus fumigatus, Aspergillus niger, Helminthosporium, Alternaria Alternata), pollens (Parthenium hysterophorus, Amaranthus spinosus), dog and cat dander and insects (cockroach, mosquito).

Out of 30 patients, who underwent skin prick test, 36% were males and 64% were females. 66% of asthmatics in the study had bronchial asthma with allergic rhinitis whereas 34% of asthmatics did not have allergic rhinitis. 90% of the study patients responded positively to allergy skin prick test. Out of the positive responders, 100% were sensitive to both the species of dust-mite, 26% were sensitive to molds, 10% were sensitive to pollens, 7% were sensitive to animal dander and food allergy to eggs was present in 3%.

The most common allergens in the study were dust-mite followed by molds. Identification of the offending allergens in bronchial asthma helps in allergen avoidance and immunotherapy for optimal control of bronchial asthma.

Relationship between serum vitamin-D and pulmonary function in adults with asthma exacerbation

Priyadarsini Parida, Sampat Dash, Hemant Kumar Sethy, Jyoti Patnaik

Department of Pulmonary Medicine, S.C.B. Medical College and Hospital, Cuttack, Odisha, India. E-mail: [email protected]

Introduction: Asthma exacerbations are the leading causes of asthma morbidity and comprise a significant proportion of asthma-related costs. Vitamin D status may play a role in preventing asthma exacerbations.

(1) to measure serum vitamin-D in patients with asthma exacerbation and compare it with stable asthma patients and normal individuals and (2) to assess the relationship between serum vitamin-D in patients with asthma exacerbation to their pulmonary function and response to treatment.

and Methods: We studied 52 asthma exacerbation cases and compared with 21 stable asthma patients and 26 normal individuals. Serum vitamin-D was analysed and categorized into deficient (<20 ng/ml), insufficient (≥20 to <30 ng/ml) and sufficient (≥30 ng/ml). Pulmonary functions were assessed by peak expiratory flow rate (PEFR), forced expiratory volume-first second (FEV 1 ) and forced vital capacity (FVC). Statistical analysis was done by SPSS software, Student's t-test and Pearson's correlation method. The degree of association between serum Vitamin-D, inflammatory markers and pulmonary function were calculated and compared with stable asthma patients and healthy individuals.

and Discussion: Among asthma exacerbation cases 98.1% had lower vitamin-D levels. Serum vitamin-D had significant negative correlation with serum C-reactive protein, erythrocyte sedimentation rate, urine microalbumin, mean leukocyte count and positive correlation with predicted day 1-5 PEFR, day 3 and day 5 FEV 1 and percentage change in PEFR.

Deficient vitamin-D levels were found in the most of asthma exacerbation cases and had inverse relationship with lung functions and rate of lung function improvement. It suggests that vitamin-D supplementation during asthma exacerbation may result in improvement in severity and treatment response.

Impact of health education and self-action plan in improving the adherence to aerosol therapy in bronchial asthma patients

G. S. Gaude, Jyothi Hattiholi, Alisha Chaudhury

Department of Pulmonary Medicine, KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India. E-mail: [email protected]

Introduction: Bronchial asthma is a common disease with high morbidity and has been observed to be associated with very poor adherence to the inhalational therapy which leads to the sub-optimal control of the disease.

Aim: To study the adherence for aerosol therapy in bronchial asthma patients and to assess the impact of health education and self-action plan in improving the compliance to the therapy.

and Methods: A prospective study was done on a total of 500 bronchial asthma patients over a period of 2 years. Once included in the study, the patients were followed-up for a total of 12 weeks for assessment of non-adherence to the aerosol therapy. In non-adherent patients, we employed various health education strategies to improve the compliance in these cases.

At the end of 12 weeks, it was observed that only 193 patients (38.6%) had regular compliance and 307 patients (61.4%) were non-compliant to aerosol therapy as prescribed for bronchial asthma. Factors that were associated with poor compliance were: Lower educational level, poor socio-economic status, cumbersome regimens, dislike for medication and distant pharmacies. After employing various strategies for improving the compliance, it was increased in176 patients (57.3%) among the earlier defaulted patients, while the remaining 131 patients (42.7%) were found to be non-compliant even after various educational techniques.

Non-compliance in asthma management is a fact of life and no single compliance-improving strategy probably will be as effective as a good physician-patient relationship.

Evaluation of allergens involved in patients with allergic rhinitis and bronchial asthma by skin prick test in Ujjain

Kallol Sinha, Arti Julka, Piyush Gupta, Abhisheka Kumar, J. C. Agrawat, Mustafa, H. G. Varudkar

Department of Pulmonary Medicine, R.D. Gardi Medical College, Surasa, Ujjain, Madhya Pradesh, India. E-mail: [email protected]

Introduction: Allergic rhinitis and asthma are the most common atopic diseases with an increasing prevalence during the last few decades in our country. Allergy skin tests are the most important diagnostic test to find out common causative allergens.

To find out the predominant allergen in allergic rhinitis and bronchial asthma by dermal sensitivity test.

Materials and Methods:
It was a prospective study. A total of 30 patients with allergic rhinitis and bronchial asthma were subjected to dermal sensitivity test with 220 allergens by modified skin prick method. A total of 6600 prick test were done and significant skin reaction was documented as 3+ and above.

There were equal males (n = 15) and females (n = 15) with age range of 10-55. Most common allergens were Alternaria atlernata (fungi)-60%; Ants (insects)-56.6%; Spider web-dust (inhalants and contactants)-50%; Cotton-dust 46.6%; Human dander and tobacco-43.3%; House dust-mite (mites)-33.3%. Common food allergens were kheera (40%), corn (40%), water nut (40%), tendi (36.6%), cucumber and cauliflower in 33.3%, guvar, lady's finger, lobster, salmon and dal-moth all 30% each. 20% patients showed improvement after avoidance of causative allergen.

Conclusion: Common allergens were identified in patients with bronchial asthma and allergic rhinitis. Avoidance of these allergens will be helpful in reducing the symptoms.

Asthma control test and its relation to the severity of asthma

Bhagyashri B. Patil, G. S. Gaude

Department of Pulmonary Medicine, KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India. E-mail: [email protected]

Introduction: Asthma is a worldwide problem. As per Global Initiative for Asthma guidelines, the goal of treatment is to achieve asthma control. In a busy clinical practice there is a need for a simple method for assessing asthma control with or without lung function testing.

Aim: (1) to compare the asthma control test (ACT) and asthma severity by spirometry and (2) to determine validity of the asthma control test as a screening tool.

and Methods: A total of 106 cases of asthma were studied for 1 year. Based on spirometry they were classified as mild, moderate and severe persistent asthma. They were classified as uncontrolled asthma and controlled asthma according to ACT score. The two tests were compared by McNemar's Chi-square test. The sensitivity and specificity was calculated. The patients were followed-up at the end of 3 months and 6 months.

and Conclusion: The sensitivity of the ACT as a screening test was 82.3% and specificity was 69.4% at the first visit. Sensitivity and specificity of ACT was 92% and 85.1% and 85.7% and 96.7% at second and third visits, respectively.


Comparison of nasal mucociliary clearance among urban and rural adult non-smoking women

K. Dhivya, Chitra Shanmugam, Abirami Omprakash, Priscilla Johnson, Padmavathi Ramaswamy

Department of Physiology, SRMC and RI, Sri Ramachandra University, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Nasal mucociliary clearance (NMC) is a key defense mechanism in human airways. Impairment of NMC results in the accumulation of respiratory secretions and reduced lung defenses leading to infections, inflammation and even neoplasia. There are several factors which can impair the NMC such as air pollution, cigarette smoking. Indoor air pollution is one of the significant risk factor for non-smoking women.

To compare the NMC among urban and rural adult non-smoking women.

and Methods: This cross sectional study involved 143 (67 urban and 76 rural) apparently healthy women of age ranging from 20 to 50 years. After getting demographic details, the NMC time was measured as time taken to experience sweet taste at nasopharynx following the placement of saccharin pellet in the nostril.

NMC time was significantly prolonged in rural women (7.55 ± 3.036 min) when compared to urban women (5.93 ± 2.40 min) population (P = 0.004).

and Conclusion: The prolonged NMC, observed in rural females, is probably due to exposure to indoor air pollutants caused by combustion of biomass fuel. Creating awareness among rural women about indoor air pollution and implementing proper intervention strategies can reduce the occurrence of respiratory


Relationship between symptom, dyspnoea modified medical research council scale and forced expiratory volume in first second in chronic obstructive pulmonary disease

V. Sai Savya, M. Sravan Kumar, M. G. Krishna Murthy, D. Dhanalakshmi

Department of Pulmonary Medicine, Kakatiya Medical College, Warangal, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Chronic obstructive pulmonary disease (COPD) is one of the most common diseases that affects many people around the world. Of the symptoms, dyspnea is an important and debilitating symptom for which most of the patients with COPD seek medical attention.

To study the relationship between dyspnea according to modified medical research council dyspnea scale (MMRC)grading and forced expiratory volume in first second (F EV 1 ) in patients of chronic obstructive pulmonary disease.

and Methods: This cross-sectional study was conducted on 54 male patients between 2012-2013 at Government Chest Diseases and Tuberculosis Hospital, Hanamkonda, A.P. COPD was diagnosed as per Gold guidelines. Patients were selected by symptoms-cough with expectoration and dyspnea. Detailed history of dyspnea was taken and graded according to MMRC dyspnea scale. Routine investigations were done. Patients were taken for pre-bronchodilator spirometry by SPIROWIN Spirometer to obtain FEV 1 . Then 2 puffs of salbutamol 200 micrograms was delivered through metered dose inhaler and 15 min later spirometry was repeated, FEV 1 was obtained and correlated with dyspnea according to MMRC scale.

This study was conducted on 54 male smokers who were diagnosed as COPD patients. In this study, dyspnea MMRC scale was correlated well with percentage predicted FEV 1 .

MMRC scale dyspnea grade is correlated well with percentage predicted FEV 1 ; more strongly with post bronchodilator % FEV 1 than with pre bronchodilator % FEV 1 .

Noninvasive ventilation in the management of acute exacerbation of chronic obstructive pulmonary disease with hypercapnic respiratory failure in ward setup

Rajat Subhra Saha, Debajyoti Paul, Surajit Chatterjee, Ritam Chakraborty

Department of Respiratory Medicine, IPGMER, Kolkata, West Bengal, India. E-mail: [email protected]

Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality and results in an economic and social burden. Acute exacerbation of COPD (AECOPD) affects the quality of life and prognosis of patient. The frequency of hypercapnic respiratory failure (RF) in AECOPD varies from 16% to 35% with overall mortality of 35-43%. In this perspective, non-invasive positive pressure ventilation (NIPPV) not only avoids ventilator associated pneumonia and airway injury but also decrease morbidity, length of hospital stay and economic burden.

To assess any improvement with NIPPV for management of AECOPD with hypercapnic RF in ward setup.

and Methods: 50 patients (mean age: 60.18, sex M:F = 4:1) with AECOPD with hypercapnic RF admitted in our ward were included and selected for NIPPV. Baseline arterial blood gas (ABG) was used to select hypercapnic RF and follow-up ABG at 2 h, 24 h and at withdrawal were measured. Baseline and follow-up clinical parameters were also recorded and compared.

and Discussion: In our study 82% patient were successfully treated with NIPPV in the ward and only 18% needed invasive ventilation. Baseline pH (7.31 ± 0.063) significantly improved at 24 h and at withdrawal. Baseline PCO 2 (67.23 ± 12.235) improvement was seen after 2 h, 24 h and at withdrawal. Mean duration of NIPPV was 7.51 days. Complications during NIPPV were mostly skin erosion (10%) and serious complications like pneumonia (8%) and sepsis (4%) were the minimum.

AECOPD with hypercapnic RF patient were successfully treated with NIPPV with help of ABG and clinical parameters with minimum complications.

Study of association of bronchiectasis in patients with COPD: A single tertiary care centre experience in India

A. Ambica, R. Ramakrishna, P. V. Prabhakara Rao

Department of Pulmonology, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India. E-mail: [email protected]

Background: Data regarding the association of bronchiectasis in patients with chronic obstructive pulmonary disease (COPD) in India are sparse. The objective of this study is to identify the association of bronchiectasis in Indian patients with moderate to severe COPD.

and Methods: Fifty consecutive patients with moderate (FEV 1 = 50% ≤70%) or severe (FEV 1 ≤50%) COPD were included prospectively between September 2011 and July 2013. Pulmonary function tests were performed in all patients. High-resolution computed tomography scan of the chest was used to diagnose bronchiectasis. Peripheral blood samples were obtained for measurement of C-reactive protein (CRP) and serum albumin. All the subjects were enquired about exacerbations through clinical questionnaire during this study period. Three sputum samples from each patient were collected for microbiologic analysis on monthly basis for 3 months. All the tests were done in a clinically stable phase for at least 6 weeks.

Results: Mean age of the patients was 63.84 ± 7.87 years. Out of 50 patients, 45(90%) were men and the remaining were women (10%). Bronchiectasis was present in 30 patients (60%). H. influenza was the commonest organism isolated from the sputum. Patients with bronchiectasis had significantly more number of COPD exacerbations (P = 0.0001), severe airway obstruction (P = 0.037), higher CRP levels (P = 0.0001) and low albumin levels (P = 0.007). Nine patients (30%) died in bronchiectasis group and one in patients without bronchiectasis (P = 0.036).

Our study showed an elevated prevalence of bronchiectasis in patients with moderate to severe COPD and was associated with severe airway obstruction, increased exacerbations, inflammation, malnutrition and mortality.

Cardiac dysfunction in patients with chronic airflow obstruction due to tuberculous destroyed lung

Ankit Singhal, Naresh Kumar

Department of Respiratory Medicine, Subharti Medical College, Meerut, Uttar Pradesh, India. E-mail: [email protected]

Introduction: India is contributing to a fifth of the global burden of tuberculosis. Tuberculous destroyed lung is diagnosed by a clear past history of tuberculosis with findings of parenchymal destruction verified by chest X-ray. Echocardiography provides rapid, non-invasive and accurate method to evaluate the cardiac changes.

We aimed to evaluate cardiac dysfunction in patients with chronic airflow obstruction due to tuberculous destroyed lung.

and Methods: A total of 52 patients were selected for study and out of them only 44 (84.6%) underwent echocardiography from June 2011 to December 2012.

and Discussion: On echocardiographic evaluation of tuberculous destroyed lung, 36% cases had normal echocardiographic parameters. Pulmonary hypertension was observed in 24/44 cases (54.54%) in which prevalence of mild, moderate and severe pulmonary hypertension were 10/24 (41.66%), 14/24 (58.33%) and 2/24 (8.33%), respectively. Cor-pulmonale was noted in 8/24 (33.33%) cases, 9.09% cases had left ventricle systolic dysfunction and 36.36% cases had evidence of left ventricle diastolic dysfunction. Left ventricle hypertrophy was found in 9.09% cases.

The present study shows high prevalence of pulmonary hypertension and cor-pulmonale in patients of tuberculous destroyed lung. So, we suggest cardiac evaluation in every patient of tuberculous destroyed lung. This will help in early intervention and better prognosis.

A comparative study on inhaled corticosteroids versus placebo in management of chronic obstructive pulmonary disease

Shone P. James, Davis Paul, Dinesa Prabhu, K. P. Venugopal

Department of Pulmonary Medicine, Kottayam Medical College, Kottayam, Kerala, India. E-mail: [email protected]

Introduction: The role of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) has been a subject of debate. Recently published meta-analyses have reported conflicting results on the effect of inhaled steroid therapy in COPD.

Aim: To assess the role of inhaled corticosteroid (budesonide - 400 ug) in the management of COPD.

Materials and Methods: Fifty Patients with Stage 3 or 4 COPD as per Gold guideline were selected. Patients with pulmonary tuberculosis sequelae, reversibility on pulmonary function test, on inhaler medication, oxygen therapy were excluded. Patients were randomly divided into two groups of 25 each and baseline forced expiratory volume-first second (FEV 1 ), number of hospitalization and exacerbations were entered. Group A: Long acting beta agonist (formoterol 6ug) + long acting antimuscarinic (tiotropium 18 ug) + placebo, administered using MDI with spacer. Group B: (formoterol 6 ug) + (tiotropium 18 ug) + Inhalational corticosteroid (budesonide 400ug), administered similarly. Patients were reviewed after 6 months and reassessed by FEV 1 , number of exacerbations/hospitalizations. Data were analyzed using paired t-test.

Results and Discussion: There was 96% reduction in exacerbation rate in group A and 80% in Group B (P < 0.05). Reduction in hospitalization rate was equal in both groups-48% (P < 0.05). The follow-up FEV 1 at the end of study did not show any statistically significant improvement in both groups. Two cases of pneumonia and candidiasis were detected in Group B.

Inhaled corticosteroids do not offer any added advantage in COPD patients with regard to number of exacerbations/hospitalizations, mortality and improvement in FEV 1 . Patients using inhaled steroids are more predisposed to local side effect like oral candidiasis.

Effect of home based pulmonary rehabilitation on health related quality of life in chronic obstructive pulmonary disease patients

John Mathew, B. Jayaprakash, K. Anitha kumari, Sanjeev Nair, Ronaldwin, Reshmi S. Nair, Sreekala, D. Rajan

Department of Pulmonary Medicine, Govt. Medical College, Thiruvanathapuram, Kerala, India. E-mail: [email protected]

Introduction: Pulmonary rehabilitation is a proven effective strategy in the management of chronic obstructive pulmonary disease (COPD), it is a neglected area in our part of world and there are very few studies on home based pulmonary rehabilitation on COPD in our scenario.

To assess the effectiveness of home-based pulmonary rehabilitation on health related quality of life, exercise tolerance, depression levels and perceived dyspnea as assessed by St. George's Respiratory Questionnaire (SGRQ), 6-min walk test (6MWT), Patient Health Questionnaire (PHQ)-9 and modified Borg scale, respectively.

and Methods: It was an interventional study with pre and post assessment test design. Pre and post rehabilitation assessment was done with: Exercise Capacity-6MWT, quality of life-SGRQ, shortness of breath-modified Borg dyspnea scale and depression scale-PHQ-9. Patients were educated about the disease and need for rehabilitation, advised smoking cessation and nutritional modification. Breathing exercise, upper limb and lower limb exercises were given for 6 weeks in a structured manner.

Of our calculated sample size of 35, 21 patients completed 6 weeks of rehabilitation, interim analysis had shown statistically significant change in SGRQ 8.7 (P < 0.0001), 6MWTD 25.2 (P < 0.03), PHQ-9 2.7 (P < 0.00001), Borg scale 0.5 (P < 0.01).

A significant improvement in quality of life, exercise tolerance, perceived dyspnea was seen along with decrease in level of depression.

Role of serum magnesium in predicting characteristics of acute exacerbations of chronic obstructive pulmonary disease requiring hospitalisation

B. Nithilavalli, R. Karthikeyan, K. Anupama Moorthy

Department of Respiratory Medicine, PSG Institue of Medical Sciences, Coimbatore, Tamil Nadu, India. E-mail: [email protected]

Background: Serum magnesium is implicated in pathophysiology of various lung diseases including chronic obstructive pulmonary disease (COPD). Scanty reports are available in literature on its effect on COPD exacerbation (AECOPD). Identifying magnesium as a modifiable risk in COPD is essential for designing treatment strategies. We aimed to evaluate the predictive role of serum magnesium in various outcomes of AECOPD requiring hospitalization.

Materials and Methods:
In a retrospective analysis, 255 admissions for AECOPD were identified in database during August 2011 to July 2013, whose data were extracted after approval from institutional ethics committee.

Serum magnesium level ranged from 1.3 to 2.3 mg/dL with a mean of 1.71 ± 0.18 mg/dL. Low serum magnesium levels were associated with prolonged hospital stay (odds ratio 3.33; 95% confidence interval [CI] = 0.32-8.39; P < 0.01) and ICU admissions (odds ratio = 2.50; 95% CI = 1.05-5.98; P < 0.05) independent of age, BMI, duration and severity of COPD. However the levels were not associated with the use of ventilators, mortality rate and time to next exacerbation. Serum magnesium significantly correlated with baseline SPO 2 in room air during stable COPD (r = 0.268; P < 0.001) but not with SPO 2 during exacerbation (r = 0.009; P = 0.915).

A lower level of serum magnesium is shown to predict prolonged hospital stay and intensive care unit admissions for AECOPD, whose mechanism is not known. Serum magnesium appears to be chronically influenced by oxygenation status of stable disease rather than acute effects during exacerbation. We recommend prospective studies for further insight into pathogenesis of AECOPD in the context of serum magnesium.

Exhaled carbon monoxide and carboxyhemoglobin% as noninvasive marker of disease severity in obstructive airway diseases

Mohammad Shameem, Asrar Ahmad, Qayyum Hussain

Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. E-mail: [email protected]

Background: It has been found that exhaled carbon monoxide (CO) levels are elevated in untreated asthmatic patients than in non-smoking healthy controls.

Materials and Methods:
The subjects were recruited through the Department of TB and Respiratory Diseases, Jawaharlal Nehru Medical College Hospital, Aligarh. Exhaled CO and % carboxyhemoglobin (COHb) were measured on a portable piCO + smokerlyzer (breath CO monitor, Bedfont Scientific Ltd., Kent, England). Data were expressed in mean ± structural equation modeling statistical analyses were performed with SPSS for Windows (version 16.0; SPSS Inc) and Graph Pad Prism 5.01.

The mean exhaled CO level was found to be remarkably higher in asthmatic patients (6.13 ± 0.42 ppm, P < 0.05) than in controls (4.62 ± 0.41 ppm). The mean exhaled CO level was significantly higher among COPD patients, 6.47 ± 0.44 ppm, (P < 0.01), while there was no marked difference between asthma and COPD (P > 0.05). The % COHb levels were significantly higher in COPD and asthma patients as compared to control. The values being 1.67 ± 0.07, 1.61 ± 0.08 and 1.37 ± 0.07, respectively (COPD vs. control, (P < 0.01); asthma vs. control, P < 0.05). The negative correlation was found between exhaled CO and FEV 1 (% predicted) in asthma and COPD patients, r = −0.30, P < 0.05 and r = −0.25, P > 0.05, respectively. It was also observed that there was a negative correlation found between exhaled CO and FEV 1 % predicted in controls (r = −0.41, P < 0.01).

Exhaled CO and % COHb can be used as non-invasive marker of disease severity in obstructive airway diseases and treatment response.

A study of disturbance in serum Mg 2+ levels in patients of chronic obstructive pulmonary disease

Anand Agrawal, Himanshu, Madan Chandermani

Department of Respiratory Medicine, BPS Govt. Medical College for Women, Khanpur Kalan, Sonipat, Haryana, India. E-mail: [email protected]

Introduction: Hypomagnesemia has been cited as a predictor of acute exacerbations of chronic obstructive pulmonary disease (COPD) and an independent risk factor for frequent hospital readmissions due to the same.

To study the disturbance in serum Mg 2+ levels in patients with acute exacerbation of COPD.

and Methods: A case-control hospital based multi-group study with 50 patients in each group was designed to study the disturbance in serum magnesium in patients of COPD with acute exacerbation. Subjects were divided into three groups: (1) patients presenting to the emergency with an acute exacerbation of COPD; (2) healthy controls; 3) known cases of COPD presenting to the OPD for follow-up. Data were analysed using tests of significance and P < 0.05 was considered significant.

A severe and statistically significant diminution of serum Mg 2+ levels was found in patients presenting with an acute exacerbation of COPD (mean serum Mg 2+ = 0.33; 95% confidence interval [CI] = 0.17-0.49) compared to healthy population (mean serum Mg 2+ = 0.51; 95% CI = 0.43-0.59). The serum Mg 2+ levels of patients presenting with an acute exacerbation was also significantly less than stable COPD patients presenting for follow-up (mean serum Mg 2+ = 0.40; 95% CI = 0.26-0.54).

The study confirmed the presence of diminished serum Mg 2+ concentration at statistically significant levels in patients with acute exacerbation of COPD.

A cross sectional study design to analyze the prevalence of anemia in chronic obstructive pulmonary disease patients

Pritish Maheshwari, Sudheer Nadimpalli, Mohd Samiuddin

Department of Pulmonology, Mediciti Hospitals, Hyderabad, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Non-pulmonary signs and symptoms of chronic obstructive pulmonary disease (COPD) have led to a shift in the focus of diagnostic and therapeutic strategies. Abnormal inflammatory response associated with COPD may provoke other disorders such as anemia of chronic disease. Anemia is an independent predictor of mortality in several chronic diseases and may have a clear detrimental impact on patient's health, including dyspnea, exercise tolerance and quality of life.

Aim: To find out the prevalence of anemia among different Stages of COPD and comparing it with different demographic variables (age, sex and smoking).

Materials and Methods: We investigated 106 diagnosed cases of COPD in our hospital from 2011 to 2013. Prior informed consent was taken. History and clinical examination, spirometry (pre and post bronchodilator), complete hemogram and routine biochemistry were recorded. Chi-square test was applied for statistical analysis.

Results: Study constituted 83% males and 17% females; 62.26% (n = 66) smokers and 37.74% (n = 40) non-smokers; mean age, 52.3 ± 10.7 years. Out of 106 patients, 49% (n = 52) were anemic, 13.2% (n = 14) were polycythemic. Anemia was present in 39% of Gold Stage I, 41.5% of Stage II, 66.67% of Stage III and 100% of Stage IV COPD. Of anemic patients, 27 were smokers and 25 were non-smokers (P = 0.031). Polycythemia was present in 18% of smokers and 5% of non-smokers. Of polycythemic patients 12 were smokers and two were non-smokers (P = 0.05).

Conclusion: Anemia and polycythemia are frequently existing co-morbidities in COPD. Occurrence of anemia increases with severity of COPD. Smoking predisposes to both anemia and polycythemia. Occurrence of anemia and polycythemia increases with smoking status of individual.

Burden of obstructive lung diseases in Bangladesh

G. M. M. Habib, M. R. Hassan, M. M. Rahman, M. A. Hossain, A. M. Mahmud, K. S. Bennoor, A. Mustafa

IPCRG-BD, Khulna, Bangladesh. E-mail: [email protected]

Aim: To estimate the prevalence of chronic obstructive pulmonary disease (COPD) in Bangladesh.

Materials and Methods: Total 3028 subjects of >40 years of age were studied. There were three major strata - metropolitan, urban and rural. In all stages, stratified random sampling method was followed. A pre-tested questionnaire was filled-up with face-to-face interview with the respondent. Spirometry with reversibility test was done in all subjects. A fixed ratio of forced expiratory volume 1/forced vital capacity <70%, not reversed after bronchodilation with 200 mcg of salbutamol inhalation was taken as diagnostic criterion for COPD.

Results: Prevalence of COPD in >40 years population was 21.24% (95% confidence interval [CI] = 20.77-21.78). The over all prevalence is 4.32%. It was highest for rural population 23.15% (odds ratio 1.19, 95% CI = 0.99-1.43), followed by urban 22.62% (odds ratio 1.13, 95% CI = 0.94-1.36) and lowest for metropolitan population 17.77% (odds ratio: 0.73, 95% CI = 0.59-0.89). Again from our findings it was obvious that exposure to bio-mass fuel (open stove/wood burn) appears to be a significant risk factor in developing COPD, >80.00% (82.21%).

Conclusion: Prevalence of COPD in >40 years population was 21.24%. It was highest for rural population, followed by urban and lowest for metropolitan. The exposure to bio-mass (open stove/wood burn) appears to be a significant risk factor in developing COPD.

Association between chronic obstructive pulmonary disease and chronic renal failure: Investigative study in a tertiary health care centre Mahbubnagar dist., Andhra Pradesh

Joe Jose Mathew, Pradyut Waghray,

A. N. V. Koteswara Rao, Venkateswara Reddy Tummuru, V. Veena

Department of Pulmonary Medicine, S.V.S.M.C., Mahabubnagar, Andhra Pradesh, India. E-mail: [email protected]

Background: Lean mass is frequently reduced in chronic obstructive pulmonary disease (COPD) and the glomerular filtration rate (GFR) might be depressed in spite of normal serum creatinine (concealed chronic renal failure [CRF]). We investigated the prevalence of both concealed and overt CRF in elderly patients with COPD.

Materials and Methods: The study was conducted in Department of Pulmonary Medicine, S.V.S. Medical College and Hospital; Mahbubnagar, Andhra Pradesh. We evaluated 80 consecutive elderly outpatients with COPD attending our pulmonary medicine department from June 2012 to August 2013. The GFR was estimated using the modification of diet in renal disease study group. Patients were categorized as having normal renal function (GFR ≥ 60 mL/min/1.73 m (2)), concealed CRF (normal serum creatinine and reduced GFR), or overt CRF (increased serum creatinine and reduced GFR). Independent correlates of CRF were investigated by logistic regression analysis.

Results: The prevalence of concealed CRF was 17 (21.2%) and overt CRF was 18 (22.5%) in patients with COPD. Corresponding figures in controls were 10.0% and 13.4%, respectively. COPD and age were significantly associated with both concealed CRF and overt CRF.

Conclusions: CRF is highly prevalent in patients with COPD, even with normal serum creatinine and might contribute to selected conditions such as anemia that are frequent complications of COPD.

Elevated serum C-reactive protein levels in stable chronic obstructive pulmonary disease patients

Rameshwara Kumar Mosali, Palvai Rajesh Kumar, Raju Ch, A. Sathya Prasad

Department of Pulmonary Medicine, Mamata Medical College, Khammam District, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Serum C-reactive protein (CRP) levels are increased in patients with chronic obstructive pulmonary disease (COPD). Normally CRP is used as a predictive factor for determining the prognosis of disease. It has not yet been defined whether this increase is due to the disease itself, ischemic heart disease or cigarette smoking. Serum CRP levels were measured in COPD patients without ischemic heart disease and in healthy subjects. We evaluated its relation with cigarette smoking, severity of dyspnea, severity of disease.

Materials and Methods: An observational study was done on 30 stable COPD patients. All patients were males. The exclusion criteria included ischemic heart disease and other causes of increased CRP. Control group consisted of 30 healthy men. Samples were selected consecutively. Serum CRP was measured by enzume linked immunosorbent assay.

Results: There was a significant difference between serum CRP levels of COPD patients without ischemic heart disease (45.24 ng/ml) and healthy subjects (25.39 ng/ml) (P = 0.01).There was a statistically significant relation between the serum CRP levels and the severity of dyspnea in COPD patients (P = 0.04). No significant association between CRP levels and the severity of disease was found and there was no significant difference between serum CRP and cigarette smoking in COPD patients and healthy subjects.

Conclusion: Results showed that COPD can increase the serum CRP without ischemic heart disease and cigarette smoking. Since CRP is known as a systemic inflammatory marker, it can be used for follow-up of patients and evaluation of treatment methods.

Cardiac evaluation in chronic obstructive pulmonary disease patients with moderate to severe obstruction

Abhisheka Kumar

Department of Pulmonary Medicine, R. D. Gardi Medical College, Surasa, Ujjain, Madhya Pradesh, India. E-mail: [email protected]

Introduction: COPD is a very common disease affecting smokers. It is one of the leading causes of morbidity and mortality in adults all over the world. The cardiovascular sequel of COPD has been recognized for decades. The spectrum of cardiovascular disease includes heart failure, pulmonary hypertension (PH), coronary artery disease (CAD) and arrhythmias.

Aim: Cardiac evaluation in COPD patients with moderate to severe obstruction.

Materials and Methods: It was a retrospective study, a total of 25 patients confirmed by clinical history, radiology of chest and pulmonary function test were selected from patient coming to Concord Repatriation General Hospital and investigated by spirometry and diagnosed as COPD and classified according to GOLD guidelines and subjected to resting two-dimension transthoracic Doppler echocardiography. Echocardiography reviewed to assess the pericardium, valvular anatomy and function, left and right side chamber size and cardiac function.

Results: There were 24 males and 1 female within age group of 35-70. The most common cardiac abnormality observed was right side chamber dilation (32%), left ventricular systolic dysfunction was seen in 16%, PH was seen in 20% where as severe pulmonary arterial hypertension was seen in 12%, tricuspid regurgitation was present in 28%. 24% of patient with moderate to severe obstruction presented with congestive cardiac failure.

Conclusion: Cardiac abnormalities clearly contribute to the overall morbidity associated with COPD, an understanding of their role and potential for treatment is vital.

Risk factors for reduced bone mineral density among elderly patients with chronic obstructive pulmonary disease

G. S. Gaude, Jyothi Hattiholi, Alisha Chaudhury

Department of Pulmonary Medicine, KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India. E-mail: [email protected]

Introduction: Osteoporosis is one of the major extra-pulmonary manifestations of chronic obstructive pulmonary disease (COPD). The present study was undertaken to assess the bone mineral density (BMD) and osteoporosis in the elderly COPD patients.

Materials and Methods: The prospective study was carried out in elderly COPD patients. History of the patients was taken using a detailed questionnaire. Spirometry was done to stage the severity of COPD. Dual-energy X-ray absorptiometry scan of the lumbar spine were performed using bone densitometer. Osteoporosis was defined as per World Health Organization's criteria. Statistical analysis for association of COPD with osteoporosis was done using Chi-square test. Risk factors were identified by univariate and multivariate logistic regression analysis.

Results: A total of 70 elderly COPD patients were included. Forty-six patients (65.7%) had osteoporosis and 13 (18.6%) had osteopenia. Majority of the osteoporosis patients had Stage III or Stage IV COPD (77.2%). As the severity grade of COPD increased, the risk of osteoporosis also increased. Also, with the increasing severity of COPD, BMD decreased. Patients with lower body mass index (BMI) had higher prevalence of osteoporosis (45.7%). Using multivariate regression analysis, Stage IV COPD, number of acute exacerbations >3 and steroid cumulative dose >1000 mg were independent risk factors for osteoporosis in elderly COPD patients.

Conclusions: The prevalence of osteoporosis was 65.7% and 18.6% had osteopenia. Stage III and IV patients had significantly lower BMI in elderly COPD patients. High clinical suspicion and early diagnosis and treatment are required in the evaluation of osteoporosis in elderly COPD patients.

A study of serum C-reactive protein levels in acute exacerbations of chronic obstructive pulmonary disease patients attending chest hospital

Sourabh Pahuja, Sudhir Chaudhri, P. K. Singh, Kumar Anand, Verma Sanjay, Kumar Avdhesh, Verma Sushil kumar, Bhagoliwal Ajay

Department of TB and Respiratory Disease, GSVM Medical College, Kanpur, Uttar Pradesh, India. E-mail: [email protected]

Introduction: C-reactive protein (CRP) is increasingly being evaluated for detecting low grade systemic inflammation in c hronic obstructive pulmonary disease (COPD). It is shown to be associated with increased rate of hospitalizations and mortality in patients with acute exacerbation of COPD.

Aim: (1) to assess the levels of serum CRP in acute exacerbation of COPD and to compare it in the same patients in their stable states and (2) to evaluate clinical severity of exacerbations viz-a-viz levels of serum CRP.

Materials and Methods: In this prospective study 106 patients were enrolled, out of which 76 were cases of COPD with acute exacerbation. Control group comprised of 30 patients in acute exacerbation of bronchial asthma (10), pneumonia (15) and acute respiratory distress syndrome (ARDS) (5). CRP levels were measured at time of acute onset and after recovery in both the groups. A comparison of two such readings was made.

Results: Out of 106 patients, 72 were males and 34 were females. 76 cases of COPD had mean CRP levels during exacerbation 15.54. After recovery, the mean CRP levels became 1.37. The mean CRP of pneumonia during acute illness was 20.54 and after recovery was 1.01. Similarly levels among asthma patients during acute attack levels were 2.71 and during recovery 0.52 and in ARDS patient during acute illness was 27.1 and during recovery was 0.76 . The mortality rate and CRP levels in COPD with exacerbations were correlated.

Conclusion: CRP level is a good indicator of severity of exacerbation of COPD and also prognosis.

A study of 50 cases of lung cancer

Jaydeep M. Odhwani, Chirag A. Gangajalia, Amit R. Dedun, Rajesh N. Solanki

Department of Pulmonary Medicine, BJMC, Ahmadabad, Gujarat, India. E-mail: [email protected]

Introduction: In the 21 st century lung cancer emerged as the most common cause of malignant disease in world. Lung cancer contributes about 13% of all cancers.

Aim: To study clinical, radiological and histopathological profile of the lung cancer patients.

Materials and Methods: In current study patients between age group from 40 to 70 year were included over a period of 12 months in 2012. 50 participants, already diagnosed with lung carcinoma on basis of their clinical history, diagnostic procedure e.g., bronchoscopy, thoracoscopy, were included.

Results: Out of the 50 patients studied, it was observed that male patients 45 (90%) outnumbered the female patients 5 (10%). Majority of patients were in age group of 50-59 years, 23 in number (46%). Smoking was found to be the commonest risk factor among 44 (88%) followed by occupational risk factor among 10 (20%). Weight loss, cough and hemoptysis were the predominant symptoms present in 80%, 74% and 48% of cases, respectively. Parenchymal lesions were present in 37 (74%) cases, 19 (38%) had pleural effusion and 14 (28%) had hilar prominence on chest X-ray. Commonest histopathological pattern was squamous cell carcinoma in 33 (66%) followed by adenocarcinoma in 12 (24%) and small cell carcinoma in 5 (10%).

Conclusion: Study showed that incidence of lung carcinoma was commonest among 50-59 years with smoking as the most common risk factor and squamous cell carcinoma was the main type. To conclude, an old age patient with history of chronic cough, unexplained weight loss, hemoptysis should be evaluated for lung cancer.

A study to evaluate the sensitivity of contrast enhanced computed tomography in differentiating benign from malignant intrathoracic mass lesions and it's correlation with computed tomography guided biopsy/fine needle aspiration cytology

R. Indhumathi, Roshini Koshy, K. H. Kisku, Manjiri Phansalkar, Dilip Phansalkar

Department of Radiodiagnosis, Pondicherry Institute of Medical Sciences, Puducherry, India. E-mail: [email protected]

Introduction: Intrathoracic mass lesions are common radiological findings in both symptomatic and asymptomatic patients and evaluation of these lesions remains a diagnostic challenge in modern medicine.

Aim: To evaluate the sensitivity of contrast enhanced computed tomography (CECT) in differentiating benign and malignant intrathoracic mass lesions and correlating it with CT guided biopsy/fine needle aspiration cytology (FNAC).

Materials and Methods: 40 patients were studied. Lesions from lung, mediastinum and pleura were included. All the patients underwent unenhanced and contrast enhanced CT with 5 mm collimation. Morphological parameters were initially assessed in unenhanced CT and contrast enhancement was analyzed for peak attenuation and net enhancement. After obtaining proper consent, CT-guided transthoracic biopsy/FNAC, using coaxial needle technique was done.

In unenhanced CT among all parameters, spiculated margin showed a sensitivity of 93% (26 out of 28), specificity of 25% (9 out of 12). In CECT, net contrast enhancement with cut off value of <15 Hounsfield units (HU) for benign masses and >20 HU for malignant masses showed a sensitivity of 96% (27 out of 28 cases), specificity of 75%, positive predictive value of 90% and negative predictive value of 90%. Out of the total 40 cases, 12 cases (30%) were classified as benign, 28 cases (70%) as malignant by histopathologic examination diagnosis.

Conclusion: Among all the parameters, contrast enhancement with a cut off value of <15 HU for benign masses and >20 HU for malignant masses showed highest sensitivity of 96% and hence had a high potential in differentiating benign from malignant intrathoracic masses.

Relationship between chest X-ray and pathological cell types of lung cancer

Arnab Saha, Santanu Ghosh, Kaushik Saha,

Anirban Biswas

Department of Pulmonary Medicine, Burdwan Medical College, Burdwan, West Bengal, India. E-mail: [email protected]

Introduction: Chest radiography is an essential initial investigation for suspected cases of bronchogenic carcinoma and can be a predictor of malignancy.

Aim: To assess the radiographic presentation and distribution of the different pathological cell types of lung cancer in our hospital.

Materials and Methods: Consecutive 125 suspected lung cancer patients, who had initial chest X-ray lesions suspicious of malignancy (mass lesion, nodules, pleural effusion, evidence of bronchial obstruction such as collapse, unresolved consolidation etc.) were taken as study population. Contrast enhanced computed tomography (CT) scan of thorax, CT guided fine needle aspiration cytology, fiber-optic bronchoscopy and trucut biopsy was done in the patients as feasible to find out the pathological cell type of bronchogenic carcinoma.

Results: In our study squamous cell carcinoma was the predominant cell type (47.12%) followed by adenocarcinoma (29.81%). Squamous cell carcinoma and small cell carcinoma commonly presented as central lesion whereas adenocarcinoma and large cell carcinoma manifested most frequently as peripheral lesions. Common radiographic presentation of squamous cell carcinoma was collapse (38.78%) followed by unresolved consolidations (28.57%) and masses, whereas adenocarcinoma mostly presented as nodules (38.71%) followed by pleural effusion (29.03%). Small cell carcinoma, large cell carcinoma and poorly differentiated carcinoma mostly manifested as mass lesion on chest radiography.

Conclusion: Chest roentgenography can provide a clue about the pathological cell types of bronchogenic carcinoma especially in cases of hilar or parahilar lesions, collapse, non-resolving consolidations and effusions.

To study clinical profile of lung cancer at a tertiary care centre

Sushant Muley, T. M. Dhamgaye, Vishwanath Pujari, Rahul Lokhande, Rakesh Waghmare, B. B. Bhadke

Department of Pulmonary Medicine, V.N.G.M.C. Yavatmal, Maharashtra, India. E-mail: [email protected]

Introduction: Lung cancer is the most common cause of cancer-related death worldwide accounting for more than one-third of all lethal cancers.

Aim: To study the clinical, radiological and histological profile of lung cancer and to compare the diagnostic yield of various procedures in lung cancer.

Materials and Methods: 60 patients were included in the study over a period of 2 years. These were investigated according to a study protocol which included a detailed history of the disease, smoking habits, X-ray chest, computed tomography of the chest and upper abdomen, flexible bronchoscopy with brushings and biopsy and computed tomography guided biopsy of peripheral mass lesion.

Results: 35% patients were non-smokers. The male-female ratio was 3:1. Adenocarcinoma (48.33%) was the most common cell type observed. Adenocarcinoma was the most common cell type in both sexes. Most common presentation on chest X-ray was a mass lesion. Bronchial brushing cytology yielded positive results in 60% of cases. Yield of endobronchial biopsy was 63.63% and transbronchial biopsy was 60%. Computed tomography guided biopsy yielded positive results in 94.28% of peripheral tumors. At presentation 78.17% patients were inoperable. Out of 29 patients presenting with Stage IV lung cancer, 10 patients had distant metastasis to liver, 7 to brain and 3 to adrenal gland.

Conclusions : Male sex, age >50 years and smoking are risk factor for lung carcinoma. Fiberoptic bronchoscopy with brushings and biopsy, computed tomography of the chest and upper abdomen are useful investigations in the diagnosis of lung carcinoma.

Diabetes mellitus and lung cancer: Review of the literature

Suddhasatwya Chatterjee, Soumitra S. Datta, Sandip Sarkar, Subir Sinha, Sanjay Chatterjee

Department of Medicine, Tata Medical Center, Kolkata, West Bengal, India. E-mail: [email protected]

Aims and Objectives: The current systematic review is on the incidence and survival time since diagnosis in people diagnosed to have lung cancer for those who have diabetes as compared to non-diabetic population.

Materials and Methods: MEDLINE database was searched (January 2000 to December 31, 2011). We also hand searched research papers from relevant journals and went through the reference list of the included studies articles. Search terms used were - lung cancer, mortality, survival and incidence. Studies screened from abstract were1700, full text articles screened were 40, studies excluded were 33, studies finally included were 7 and usable data extraction for meta-analysis could be done from four studies.

Results: Incidence of lung cancer in patients with diabetes as compared to those without diabetes is slightly lower. Survival time of patients with lung cancer, if they have diabetes, is longer as compared to patients without diabetes.

Discussion and Conclusions: Diabetes may have a mild protective effect on the course and prognosis of patients with lung cancer. This could be due to various factors as (1) cessation of smoking following diagnosis of diabetes (2) more regular health checkups in patients with diabetes (3) biological factors associated with cellular glucose metabolism (starving cancer cells of glucose) (4) Anti-diabetic therapy (specially metformin and pioglitazone) may have some anti-cancer properties. The above effect is worth exploring for better understanding on lung cancer biology and development of treatment strategies in future.

Clinico-radiological patterns misleading to initiation of antitubercular treatment in carcinoma lung patients

Anurag Agrawal, Apoorv Sinha, Rajeev Tandon, Lalit Singh

Department of Pulmonary Medicine, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Introduction: High prevalence of tuberculosis and its clinical and radiological similarities with carcinoma lung leads to wrong prescription with antitubercular treatment (ATT) in carcinoma lung patients, thereby leading to delay in diagnosis and progression of cancer.

Aim: To find out the clinical and radiological patterns associated with wrong diagnosis of tuberculosis and initiation of ATT in carcinoma lung patients.

Materials and Methods: It was a retrospective study in which data of 195 patients diagnosed as carcinoma lung in the Department of Respiratory Medicine at SRMSIMS, Bareilly over 2 years was analyzed for wrong initiation of ATT.

Results: Of 195 diagnosed cases of carcinoma lung, 79 patients (40.5%) were taking ATT for at least 1 month (range: 1 month to 12 months), of which 51 patients (26%) had also received ATT in past. Two sample sputum microscopy for acid fast bacilli was done only in 102 patients; 6 patients came positive for acid fast bacilli (AFB) but ATT was started in 56 patients. Age less than 50 years, upper zone involvement, bilateral lesions, multiple zone lesions, past history of tuberculosis and presence of pleural effusion were more common in patients with carcinoma lung wrongly started on ATT. The mean delay in diagnosis of lung cancer in these patients was 3.2 months (range: 1 month to 12 months).

Conclusion: We found that a large number of carcinoma lung patients were misdiagnosed as a case of tuberculosis which led to significant delay in diagnosis of cancer. Failure to rely on sputum microscopy for AFB and over-reliance on chest radiograph to diagnose tuberculosis were the major doctor related errors.

A study of incidence of dual pathology- pulmonary tuberculosis with lung malignancy: Experience of BJMC Ahmadabad

Pankaj Gupta, Savita Jindal, Nalin T. Shah,

Kusum V. Shah

Department of Pulmonary Medicine, BJMC Ahmadabad, Gujarat, India. E-mail: [email protected]

Introduction: With the increasing incidence of pulmonary tuberculosis in older patients, that too in India which is an endemic region, the presence of concomitant pulmonary tuberculosis and lung malignancy has stimulated great interest. Missing the diagnosis of either one of the two in a patient with dual pathology would lead to adverse outcomes. Tuberculosis might get worsened by chemotherapy and lung malignancy if not diagnosed early might get metastasized and incurable.

Aim: To study the incidence of dual pathology in 50 cases of radiologically suspicious lung malignancy who were subjected to fiberoptic bronchoscopy in our hospital over a period of 6 months.

Materials and Methods: The patients were subjected to fiberoptic bronchoscopy and materials (biopsy, BAL) were taken for histopathological and microbiological investigations.

Results: Out of 50 patients, there were 23 (46%) adenocarcinoma, 14 (28%) squamous cell carcinoma, 3 (6%) small cell carcinoma, 4 (8%) dual pathology and 5 (10%) negative.

Conclusion: Lung malignancy and pulmonary tuberculosis are two major public health problems. Often achieving a diagnosis would give the physician a "Satisfaction of Search" and the other diagnosis tends to be missed. So, high degree of suspicion is required to diagnose dual pathology.


Bronchoscopic analysis in sputum negative pulmonary tuberculosis

Unni R. Baby, Girija Nair, Jayalakshmi, Abhay Uppe, Lavina Mirchandani, Aparna Iyer, Mugdha Bhide

Department of Pulmonary Medicine, Padmashree Dr. D. Y. Patil Hospital and Research Center, Mumbai, Maharashtra, India. E-mail: [email protected]

Patients of sputum negative pulmonary tuberculosis may not be excreting bacilli continuously or may not be producing enough sputum and hence are smear negative. We tried to check how many of them were bringing out mycobacterium in their sputum by bronchoscopic aspirate.

Aim: To study the increased rate of diagnosis of pulmonary tuberculosis by bronchoalveolar lavage (BAL) in sputum non-producers and smear negative patients.

Materials and Methods: BAL was performed on 40 patients (sputum non-producers and smear negative). Smear analysis (by Ziehl Neelsen technique) and culture for mycobacteria by BACTEC 960 tuberculosis (TB) - MGIT was performed. Post bronchoscopy sputum smear analysis was also performed. At the time of bronchoscopy none of the patient had received any antitubercular treatment.

Results: 22.5% (9/40) where sputum non-producers while 77.5% (31/50) were smear negative. 7.5% (3/40) were post bronchoscopic sputum smear acid fast bacilli (AFB) positive while 35% (14/40) were BAL smear AFB positive. 45% (18/40) were mycobacterial culture positive at 3 weeks while 57.5% (23/40) were culture positive at 6 weeks.

Conclusion: The study highlights increase in diagnostic yield from 7.5% to 57.5% with use of bronchoscopy and sample culture by BACTEC TB MGIT. 57.5% patients with sputum smear negative pulmonary TB were also excreting TB bacilli and hence this is of public health importance.

Cryo-recanalization: A novel therapeutic approach for central airway obstruction

Vaibhav Chachra, Pratibha Gogia, Rajiv Goyal

Department of Respiratory Medicine, Jaipur Golden Hospital, Pitampura, Delhi, India. E-mail [email protected]

Endobronchial cryotherapy had been used as a slow therapy where the cryoprobe is touched on the tumor surface and causes necrosis due to excessive cooling in rapid freeze thaw cycles. The resultant shedding of dead tissue takes a couple of weeks and results in slow debulking. Recently researchers have found that rapid debulking can be done by burying the probe into the tumor and freezing large chunks, which can be then removed. This process has been called 'Cryo-recanalization'.

Materials and Methods: Flexible bronchoscope was used for cryorecanalization in a patient with high-grade stenosis of the trachea from an exophytic tumor. The FOB was passed through an laryngeal mask airway device with the patient on conscious sedation and local anesthesia. The tumor tissue was frozen on the tip of the probe and satisfactory clearance of the airway could be achieved in one sitting.

Discussion: Cryorecanalization permits effective, safe and inexpensive treatment of endobronchial stenoses of the respiratory tract. Other therapeutic options (argon plasma coagulation, laser and electrocautery) have significant rates of severe complications, including bleeding, fire, airway perforation and stenosis. Using a cryorecanalization probe, the airway lumen could be restored by removing large fragments of tumor tissue, which can also be used for histopathology. Recanalization of tumor stenoses can be done in a single intervention with minimal complications. Cryotherapy also increases the efficacy of chemotherapy and radiotherapy.

Conclusion: Despite its high efficacy, low cost and relative safety, this technique remains underutilized but is re-emerging.

Mini bronchoalveolar lavage versus bronchoscopic BAL in intubated patients in a tertiary care centre, Mahabubnagar dist., Andhra Pradesh

V. Veena, Pradyut Waghray, A. N. V. Koteswara Rao, Venkateswara Reddy Tummuru, Joe Jose Mathew

Department of Pulmonary Medicine, S.V.S.M.C., Mahabubnagar, Andhra Pradesh, India. E-mail: [email protected]

Background: Isolation of organisms in intubated patients has posed a lot of problems. Invasive procedures have been used to obtain respiratory samples for culture. The invasive procedures like bronchoscopic guided or blind bronchoalveolar lavage (BAL), tracheal aspirate and bronchial brushings are being used.

Aim : To the aim of the study is to find the efficacy of isolation of organisms using MINIBAL when compared with bronchoscopic method in intubated patients.

Materials and Methods: The study was conducted in Department of pulmonary medicine and critical care unit, S.V.S. Medical College and Hospital; Mahbubnagar, Andhra Pradesh. Intubated patients with consolidation labeled as ventilator associated pneumonia or health care associated pneumonia were included in the study.

Results: The observations were made in 30 patients. In all the 30 patients both MINIBAL (with Ryle's tube and mucus trap) and bronchoscopic BAL were done randomly. Out of 30 patients, organisms were isolated in 28 patients with bronchoscopic BAL. With MINIBAL organisms were isolated in 22 patients without any complications.

Conclusion: In patients who are intubated BAL plays a vital role in isolating organisms. Bronchoscopic BAL is a costly procedure and is difficult to perform. MINIBAL is an easy procedure, cost effective and sufficiently effective in isolating organisms.


Outcome of thoracoscopy in undiagnosed pleural effusion

Kalpesh Panchal, Savita Jindal, Nalin T. Shah, Kusum V. Shah

Department of Pulmonary Medicine, BJMC Ahmedabad, Gujarat, India. E-mail: [email protected]

Introduction: Pleural effusion, a common respiratory illness, sometimes poses a diagnostic challenge even after thorough evaluation that includes detailed history, clinical, radiological and pleural fluid examination (biochemical, microbiological, cytological). In such situation, thoracoscopy may help in resolving the dilemma.

Aim: To study the outcome of thoracoscopy in undiagnosed pleural effusion.

Materials and Methods: 15 patients of pleural effusion in which diagnosis was not made by routine pleural fluid examination (biochemistry/microbiological/cytological evaluation) were subjected to video thoracoscopy and biopsy, pleural fluid taken for pathological examination and therapeutic intervention such as adhesiolysis was done. Intercostal drain was kept.

Results: Patients had different outcomes - some had specific diagnosis such as malignancy, empyema or tuberculosis and some with non-specific inflammatory changes.

Conclusion: Thoracoscopy should be the Investigation of choice of undiagnosed pleural effusion as it has good yield with minimal complications.

Experience of rigid thoracoscope in place of rigid bronchoscope for removal of foreign bodies and for taking biopsies in a tertiary care centre, Mahabubnagar dist., Andhra Pradesh

A. N. V. Koteswara Rao, Pradyut Waghray, Venkateswara Reddy Tummuru, V. Veena, Joe Jose Mathew

Department of Pulmonary Medicine, S.V.S. Medical College and Hospital, Mahabubnagar, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Rigid thoracoscope is an instrument to visualize the pleural cavity and the intra thoracic structures. It is also used for taking biopsies, breaking adhesions and for pleurodesis. Rigid bronchoscope is an instrument to visualize the trachea and proximal bronchi also used for removal of foreign bodies and taking biopsies.

Materials and Methods: The study was conducted in Department of Pulmonary Medicine, S.V.S.Medical College and Hospital; Mahbubnagar, Andhra Pradesh. In our institute we used rigid thoracoscope as rigid bronchoscope under local anesthesia (L.A) and deep sedation in 10 cases.

Results: Six cases were foreign body removal, 2 cases were biopsied for intrabronchial growths and 2 cases had bronchoalveolar lavage (BAL). All the procedures were successful without any complications.

Conclusion: Although rigid bronchoscopy is a safe and well tolerated procedure, the rigid thoracoscope is having a wider working channel and a separate suction channel which can be used for oxygen supplementation, which is very much similar to rigid bronchoscope. One can use rigid thoracoscope as rigid bronchoscope safely for the removal of foreign bodies, taking biopsy and for doing BAL if rigid bronchoscope or fiber-optic bronchoscope is not available.


Proportion of combined pulmonary fibrosis and emphysema in idiopathic pulmonary fibrosis

K. M. Sajeevan, C. Davis Paul, C. P. Muraly, O. K. Mani, N. Aparna

Department of Pulmonary Medicine, Govt. Medical College, Thrissur, Kerala, India. E-mail: [email protected]

Introduction: Combined pulmonary fibrosis and emphysema (CPFE) denote the coexistence of emphysema and pulmonary fibrosis in the same patient. The present study aims at looking into the proportion of CPFE in idiopathic pulmonary fibrosis (IPF) cases.

Materials and Methods: Patients with idiopathic pulmonary fibrosis attending Govt. Medical College, Thrissur were included in the study after reviewing inclusion and exclusion criteria. high-resolution computed tomography pattern was reviewed with a radiologist who is specialized in lung imaging. A detailed history, complete physical examination, lung function tests (spirometry and Diffusing Capacity of the Lung for Carbon Monoxide) and 6MWT were done. Results were compared between CPFE and IPF alone groups.

Results: Out of 20 patients who had IPF, five patients (25%) had combined pulmonary fibrosis and emphysema. The average smoking score of CPFE patients were 362, whereas that of IPF alone group was 31 (P = 0.006). All CPFE patients had an obstructive component combined with restrictive pattern on spirometry. Mean baseline oxygen saturation and 6 min walk distance of CPFE group were 92% (P = 0.48) and 202 meter (P = 0.024) respectively whereas that of IPF alone group was 93% and 309 meter. Also DLCO reduction were more significant in the CPFE subgroup (P = 0.383).

Conclusion: Good proportion of patients with IPF also had concomitant emphysema. They had a higher smoking score and low exercise capacity when compared to those without emphysema.


Variables determining oxygen saturation on finger pulse oximeter

Ankur Pathak, Tushar Sahasrabudhe,

Shailesh Meshram, Megha Oberoi

Department of Pulmonary Medicine, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. E-mail: [email protected]

Introduction: Pulse oximetry is simple, cheap and non-invasive way to determine saturation of peripheral oxygen (SPO 2 ) as compared to arterial blood gas analysis.

Aim: The aim of this study was to determine the variables that affect measurement of oxygen saturation value on finger pulse oximeter.

Materials and Methods: A Prospective unblinded study of total sample of 100 subjects both males and females of varied age groups were included in this study. We monitored saturation of oxygen using finger pulse oximeter during febrile and afebrile condition, during normal and deep breathing, inflating BP cuff up by 40 mm of Hg, with cold extremities by applying ice packs for 30 s, patient in lateral position, during IV fluid infusion and with black-color nail paint on the digit.

Results: Measuring SPO 2 in cold extremities showed a mean fall in SPO 2 values by 6 where as measuring SPO 2 using nail paint showed a mean fall of 15 in SPO 2 values in percentage on pulse oximeter. Other variables did not show significant drop in SPO 2 values.

Conclusion: Cold extremities and presence of nail paint significantly drops SPO 2 values on pulse oximeter hence these simple variables should be taken in to account while measuring SPO 2 with pulse oximeter.

Cardiopulmonary exercise testing in unexplained breathlessness

K. Subashini, T. Balamugesh, D. J. Christopher, T. Daisy Rose Mary

Department of Pulmonary Medicine, CMC, Vellore, Tamil Nadu, India. E-mail: [email protected]

Introduction: Cardiopulmonary exercise testing (CPET) is non-invasive, objective method and provides relevant information for clinical decision making.

Aim: To evaluate the cause for unexplained breathlessness by performing CPET.

Materials and Methods: We carried out a retrospective analysis of CPET performed for unexplained breathlessness over a 1-year period. CPET was done by maximum symptom limited cardiopulmonary incremental protocol on a treadmill using modified Balke protocol with 3 min of rest, 3 min of level walking and subsequent increase in workload by constant amount each min thereafter.

Results: Unexplained breathlessness was the indication for CPET in 51 patients. The mean age was 45 years (range: 21-74 years). Mean BMI was 26.20 of which 9 (18%) were normal, 12(23%) overweight, 28 (55%) obese and 2 underweight (4%). Twenty patients (39%) did not reach anaerobic threshold (AT). Based on the AT percentage criteria, 4% were classified as diseased, 17% as deconditioned, 20% as sedentary and 20% as normal. 39 (76%) had VO2 max >80% predicted. In the final analysis, 11 (22%) had ventilatory limitation, 16 (31%) had cardiovascular limitation, 9(17%) had mixed pulmonary and cardiac limitation and 3(6.5%) had musculoskeletal limitation. Obesity was a contributory factor in 3 (6.5%). Nine (17%) had normal studies with abnormal perception of breathlessness and they were advised to gradually increase their exercise levels.

Conclusion: CPET is a useful tool in the evaluation of dyspnoea disproportionate to clinical findings and standard tests. It can be used to identify various factors contributing to breathlessness.

Effects of coronary artery bypass grafting surgery on pulmonary function tests

Namrata Jasani, N. T. Awad

Department of Pulmonary Medicine, Lokmanya Tilak Medical College, Sion, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Pulmonary dysfunction after cardiopulmonary bypass (CPB) is an important cause of post-operative morbidity. The effects of sternotomy and use of left internal thoracic artery grafts aggravate injury and delay recovery of the respiratory function. CPB induces an inflammatory response, causing an increase in the endothelial and pulmonary parenchymal injury, contributing to atelectasis and increase in the shunt and reductions of both pulmonary complacency and gas exchange.

Aim: To compare pulmonary functions and note the difference in arterial blood gases pre-operatively and post-operatively.

Materials and Methods: This prospective study was conducted at a pulmonary unit of a tertiary care public hospital. 42 patients completed the study. Patients with extensive structural abnormalities of lung and vertebrae and those with previous coronary artery bypass grafting were excluded.

Results: There was significant reduction in forced vital capacity by 13.8% within 5 week of surgery. The forced expiratory volume 1 was significantly decreased by 13.1%. After surgery mean maximum voluntary ventilation showed significant decrease of 7.6%. There was restrictive defect 4-5 weeks post-operatively. The study showed that mean change in pH was 7.40 before surgery, which decreased significantly by 0.1% after surgery. The mean PaO2 before surgery was 80.10 mm Hg and SPO 2 was 96.31%. Post-operatively, both parameters showed significant decrease of 10.1% and 2.4%, respectively.

Conclusion: Restrictive type of spirometry was seen in the post-operative state. There was a significant drop in PaO2 and SPO 2 and pH even 1 month post-operatively.

Relation between pulmonary function tests and duration of diabetes mellitus in patients with type 2 diabetes mellitus

Kalyan Kumar Kambampati, A. Sathya Prasad,

C. H. Raju, Rameshwara Kumar Mosali,

Palvai Rajesh Kumar, Dheeraj Pragati, Are Nirupama Devi

Department of Pulmonary Medicine, Mamatha General Hospital, Khammam District, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Lung mechanism and gas exchange is influenced by integrity of pulmonary connective tissue and microvasculature, abnormality in these may leads to development of variations in lung function. Diabetes mellitus is a metabolic disorder precipitating microvascular and macrovascular complications.

Aim: This study was carried out to know the relation between duration of diabetes mellitus and PFTs in type 2 Diabetes mellitus (DM) patients.

Material and Methods: 90 patients with different duration of type 2 DM (age, sex, height, weight matched) attending Mamatha General Hospital OPD/In patient ward KMM were divided into two groups, (1) duration <5 years and (2) duration >5 years. PFTs were measured by MEDSPIROR, patients were made to undergo PFTs for 3 times, every 15 min interval and best of three readings was taken. Data were statistically analyzed with descriptive statistics and Chi-square test. Exclusion criteria were smokers, non-diabetics, patients with previous/present cardio-respiratory disease and patients not willing for test.

Results: Out of 90 patients: 50 patients had restrictive type pattern (55.56%), 28 patients had normal spirometry (31.11%) and12 patients had obstructive type pattern (13.33%).

Conclusion: Though Type 2 DM patients did not have any respiratory symptoms, they did have underlying subclinical restrictive pattern of respiratory abnormality. As duration of diabetes increased restrictive profile was more significant. Spirometry is a simple, cost-effective and non-invasive diagnostic tool; its use in diabetes can help in identification of respiratory disease.


Predictive ability of stop bang and Epworth sleepiness scale in identifying obstructive sleep apnoea in a resource limited set up

Pankul Mangla, T. Dhanasekar, K. Sreedevi, B. Hariprasad

Department of Chest Medicine and TB, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Epworth sleepiness scale (ESS) and stop bang (SB) questionnaires are being used as simple screening tools for diagnosis of obstructive sleep apnea (OSA). This study is an attempt was done to validate the two in comparison to polysomnography.

Aim: To assess the predictive ability of ESS and SB in screening OSA and comparing their efficacy with polysomnography.

Materials and Methods: 25 patients with clinical suspicion of OSA were enrolled for this study following an informed consent. They were subjected to Epworth sleepiness scale and stop bang questionnaires. All patients with ESS >10 and stop bang score >3 were subjected to polysomnography.

Results: Out of 25 patients enrolled, 14 were males and 11 females. 9 patients out of 25 had Epworth score >10 and 21 patients had stop bang score >3. All 21 patients showed apnea hypopnea index (AHI) >5. 4 of the subjects had Epworth score of 0 and stop bang score of <3 and hence were not subjected to polysomnography. All 21 patients showed a linear correlation between AHI and stop bang score. 10 patients with high AHI showed Epworth score of 0. Stop bang takes into account multiple factors whereas Epworth scale measures daytime sleepiness alone.

Conclusion: Epworth sleepiness scale did not have a good correlation with the patients AHI as evidenced by a few with 0 score having very high AHI. All patients with high stop bang score had corresponding high AHI implying that this is more effective than ESS and can be used as a reliable screening tool for OSA.

Factors affecting obstructive sleep apnea in patients undergoing polysomnography in a tertiary care hospital

Abin Varghese Thomas, P. Arjun, K. A. Ameer, M. Joshi, V. Kesavan Nair

Department of Respiratory Medicine, Kerala Institute of Medical Sciences, Hubli, Karnataka, India. E-mail: [email protected]

Introduction: Though obstructive sleep apnea (OSA) is a common disorder, there is limited data available regarding its profile from India and less on the factors associated with OSA in the state of Kerala.

Aim: To study the profile and factors affecting OSA in patients undergoing polysomnography in a tertiary care hospital in southern India.

Materials and Methods: It was a retrospective observational study of 2 years from April, 2011 to April 2013. A total of 1034 patients with symptoms suggestive of OSA were subjected to attend full-channel nocturnal polysomnography in Kerala Institute of Medical Sciences, Thiruvanathapuram . Data were organized according to age, gender, Epworth sleepiness scale (ESS), collar size, body mass index (BMI) and presence of comorbidities. OSA was categorized into no OSA, mild, moderate and severe OSA according to apnea hypopnea index (AHI). Data were compiled on Microsoft Excel sheet and were analyzed using Epi Info™ 7.1.2.

Results: Age, sex, BMI, collar size, ESS, diabetes, hypertension and combined syndrome of diabetes mellitus and hypertension was significantly associated with OSA and frequency of these variables increased in the population with increasing severity of OSA. Among the patients who had OSA factors associated with severe OSA (AHI > 30) included BMI >30 (odds ratio = 1.53, 95% confidence interval [CI] = 1.15-2.02), male sex (odds ratio = 3.06, 95% CI = 2.19-4.29) and presence of diabetes (odds ratio 1.33, 95% CI = 1.01-1.76). However, after logistic regression only high BMI and male sex continued to be associated with significant OSA.

Conclusion: High BMI and male sex are associated with higher severity of OSA.

Comparing utility of Berlin questionnaire with the Epworth sleepiness scale in identifying patients with obstructive sleep apnea in a tertiary rural centre

Arti Shah, Stani Francis Ajay, Mayur Adalja, Ajay George, Dhawal Shah

Department of Pulmonary Medicine, S.B.K.S Medical Institute and R.C., Sumandeep Vidyapeeth Campus, Pipariya, Vadodra, Gujarat, India. E-mail: [email protected]

Background: The increasing sedentary lifestyle in both urban and rural population has led to lifestyle-related diseases like obstructive sleep apnea. In a resource limited setting like India, there is a paucity of health care facilities like multi-channel polysomnography, thereby further limiting the evaluation of obstructive sleep apnea (OSA) patients. Several clinically helpful questionnaires are available for detecting patients at high risk for OSA such as the Berlin questionnaire and Epworth sleepiness scale (ESS). Although questionnaires have been developed to assess symptoms of OSA, their overall reliability and utility have not been compared in rural population of Gujarat.

Aim: To compare the utility of both questionnaires for diagnosis of OSA.

Materials and Methods: Total 115 outpatients at S.B.K.S. M.I. and R.C, Piparia, Vadodara, Gujarat completed the Berlin questionnaire, ESS and underwent overnight polysomnography to determine whether they were suffering from undiagnosed obstructive sleep apnea.

Results: A total of 115 individuals were included in the study. Of these, 82.60% were males and 17.40% were females. Of these 71.30% were positive on the Berlin questionnaire, 22% were positive on the ESS, 88.7% were having OSA on polysomnography, 31% had hypertension, 10% had diabetes mellitus. Mallampati scoring class I were 17.40%, Class II were 37.45%, Class III were 39.10% and Class IV were 6.05%.

Conclusion: The Berlin questionnaire appears to be a more valid instrument for ruling out obstructive sleep apnea than Epworth sleepiness scale.

Polysomnographic evaluation in chronic obstructive pulmonary disease patient

Piyush Gupta, H. G. Varudkar, Arti Julka, Kallol Sinha, Abhisheka Kumar

Department of Pulmonary Medicine, R. D. Gardi Medical College, Surasa, Ujjain, Madhya Pradesh, India. E-mail: [email protected]

Introduction: Chronic obstructive pulmonary disease ( COPD) and its possible association with obstructive sleep apnea is a major cause of concern for clinicians. As the prevalence of both COPD and sleep apnea continues to rise, further investigation of this interaction is needed. COPD patients are at risk for hypoventilation during sleep due to the underlying respiratory dysfunction.

Aim: Purpose of the study was to know the prevalence of sleep disordered breathing in moderate and severe stages of COPD and to study if there is any correction between severity of COPD, anthropometric measures, nocturnal oxygen desaturation and polysomnographic variables.

Materials and Methods: A prospective study was done with 20 patients of COPD, diagnosed by history, physical examination and pulmonary function testing, attending RDGMC, selected and staged according to Gold criteria. All of them underwent full-night sleep study using Alice-5 polysomnographic machine.

Results: Mean apnea hypopnea index (AHI) was higher in severe COPD. TST and sleep efficiency were decreased in both the groups, more in severe group. Mean day-time SPO 2 and mean nocturnal SPO 2 were alike in both groups. Percentage of significant desaturations (T90) was more in severe COPD.

Conclusion: The prevalence of sleep apnea in moderate to severe COPD was comparatively higher than previous studies done. Occurrence of overlap syndrome was more in severe COPD, despite low BMI. Though nocturnal desaturation can occur in COPD without apneas, significant nocturnal desaturation is more common in overlap syndrome. So, significant nocturnal desaturation can be a predictor of overlap syndrome.


Combined use of pleural fluid adenosine deaminase, cytology, pleural biopsy and Mantoux test in the diagnosis of tubercular pleural effusion

Jally Vara Prasad, M. Sravan Kumar,

M. G. Krishna Murthy, D. Dhanalakshmi

Department of Tuberculosis and Respiratory Diseases/Pulmonary Medicine, Kakatiya Medical College, Warangal, Andhra Pradesh, India. E-mail: [email protected]

Introduction: Tuberculosis is one of the leading cause of morbidity and mortality worldwide affecting more than 8 million persons annually with 2-3 million deaths.Tubercular pleural effusion is the 2 nd most common extra pulmonary manifestation of tuberculosis.

Aim: To evaluate the use of pleural fluid adenosine deaminase (ADA), cytology, pleural biopsy and Mantoux test in the diagnosis of tubercular pleural effusion.

Materials and Methods: This prospective study was conducted in Government CD and tuberculosis Hospital, Hanamkonda, A.P., from 2012 to 2013. Patients with signs and symptoms of pleural effusion were admitted. Routine investigations including chest X-ray, hemoglobin, total leukocyte count, differential leukocyte count, erythrocyte sedimentation rate, urea, sugar, etc were done. Specific investigations like sputum for acid fast bacilli, Mantoux test, diagnostic thoracocentesis and pleural biopsy were done. Pleural fluid was examined for its color, protein, sugar, cytology, total leukocyte count, differential leukocyte count, malignant cells, adenosine deaminase (ADA), lactate dehydrogenase and microorganisms. Pleural biopsy was attempted and biopsy specimen was sent for histopathology examination.

Results: Study was conducted in 70 patients of pleural effusion. 52 cases had adenosine deaminase levels >40 U/L and 65 cases had lymphocyte predominance. Pleural biopsy by Copes needle in 54 cases showed caseous granuloma and 45 cases had Mantoux test positive.

Conclusion: Lymphocyte predominant exudates with high ADA value ≥40 U/L and caseous granuloma on pleural biopsy are highly suggestive of tubercular pleurisy. Combined assessment of ADA, cytology, pleural biopsy and Mantoux test is more helpful in diagnosing tubercular pleural effusion rather than individual investigation.

Microbiological diagnosis of empyema and parapneumonic effusions and the role of polymerase chain reaction

Arunhm, Natarajan Rajagopalan, Vipin Gupta, P. H. Manjunath

Department of Pulmonology and Critical Care, Narayana Hrudayalaya Hospital, Bengaluru, Karnataka, India. E-mail: [email protected]

Introduction: The diagnosis of empyema is often made on the basis of macroscopic appearance and biochemical analysis. The microbiological confirmation is often not possible because of the low culture yield. Establishment of etiology is of vital importance to institute the right treatment.

Aim: To establish the microbiological aetiology of empyema and parapneumonic effusions by polymerase chain reaction (PCR) and assess its efficacy.

Materials and Methods: Pleural fluid samples of all adult patients clinically diagnosed with empyema and parapneumonic effusion were subjected to PCR in addition to routine investigations. 3 ml of pleural fluid in EDTA vial was analysed for common aerobic and anaerobic organisms and fungi by PCR.

Results: Out of 20 patients studied so far, etiology was established by PCR in 8 patients (40%) and by conventional culture in 2 patients (10%). Streptococcus was isolated from cultures in two samples. PCR identified Acinetobacter baumannii in four samples, Klebsiella and Candida in three samples, Streptococcus pyogenes and  E.coli Scientific Name Search  in one sample each. PCR identified more than one organism in three patients.

Conclusion: In our study PCR identified etiological organism in much larger number of patients (8 vs. 2). Diagnosis was available within 6 h. This helped us with early institution of appropriate antibiotics. We believe this may help with faster and favorable resolution of empyema.


Spacer device: A potential harbor of pathogenic bacteria

Aditya Agrawal, Girija Nair, Abhay Uppe, Unni Baby

Department of Pulmonary Medicine, Padmashree Dr. D.Y. Patil Hospital and Research Center, Mumbai, Maharashtra, India. E-mail: [email protected]

Bacteria are omnipresent. Surface of a spacer device may also have bacteria on them. If such bacteria are inhaled along with the plume of medication, an infective exacerbation of obstructive airway diseases may result.

Aim: To identify bacterial growth on the surface of a spacer device.

Materials and Methods: 59 patients with chronic stable obstructive airway disease using a pressurized metered dose inhaler with a spacer, attending the outpatients department were recruited. On day 7 of use of a new spacer device, a swab was obtained from the inner surface of mouth piece, body and valve of the spacer. Gram stain and microscopy followed by plate culture of the swab were performed. 7 patients were excluded for follow-up later than 7 th day.

Results: The surfaces of 59.61% (31/52) spacers were sterile. 28.84% (15/52) had growth of the environmentally ubiquitous micrococci on the surface. 5.77% (3/52) had growth of Staphylococcus aureus of which 1 was methicllin resistant (MRSA). Pseudomonas aeroginosa, Escherichia coli and Acinetobater were found on 1.9% (1/52) each.

Conclusion: Most spacers have sterile surface or have presence of non-pathogenic micrococci. But presence of pathogenic organisms like staphylococcus (especially MRSA), pseudomonas and acinetobacter pose an increased risk of inhalation of these bacteria which in-turn could cause an infective exacerbation of the airway disease and serious systemic infections. We propose a more frequent cleaning regimen and use of antibacterial agents for disinfecting the spacer. Also frequent change of spacer device should be advocated.

Correlation of METs with lifestyle in apparently healthy individuals at a tertiary care centre

Sonal P. Karpe, Priti L. Meshram

Department of Pulmonary Medicine, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Significant lifestyle changes over the past century has resulted in increasing number of adults vulnerable to cardiovascular, respiratory and other health related diseases.

Aim: To study the exercise tolerance measured by Metabolic Equivalent Tasks (METS) in apparently healthy population as per their lifestyle and to see if physical activity in the form of moderate exercise had any bearing on it.

Materials and Methods: This study was conducted at a tertiary care hospital, with 50 adult participants of either sex. Their METS was measured using cardiopulmonary exercise testing. Subjects were classified as sedentary, which was defined as reporting less than 30 min/day of moderate exercise on 2 days/week over the previous 2 months. Subjects were advised 30 min of moderate physical activity on most days of week and followed-up after 3 months.

Results: The average METS in males was 12.97 where as in females it was 11.68 METS. The average METS in the population was 12.43. The average METS in sedentary individuals was 11.54 and in non-sedentary individuals was 13.26. In our study there was a highly significant difference in METS of sedentary and non-sedentary individuals (P < 0.0001). There was a significant improvement in METS after exercise (P < 0.01). The average METS after exercise was 13.81, i.e., there was 11.1% improvement in METS post exercise.

Conclusions: The exercise tolerance of non-sedentary subjects was significantly higher than sedentary subjects. Majority of subjects showed significant improvement in their exercise tolerance after lifestyle modification in the form of moderate physical activity.

A study on the spectrum of respiratory disorders in the elderly

Santu Kumar Samanta, Jineesh Joseph, Somenath Kundu, Kumar Abhishek

Department of Respiratory Medicine, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India. E-mail: [email protected]

Introduction: In the elderly, there is a progressive constriction of the homeostatic reserve of every organ system by a process called "homeostenosis". Presentations of a new disease depends on the organ system having made vulnerable ("weakest link" organ) by previous disease and presentations are often atypical.

Aim: Aim of this study was to observe the different type of non-respiratory presentations and outcome of respiratory disorders in elderly population.

Materials and Methods: An observational cross-sectional hospital based study on 100 cases from elderly patients admitted in the Department of Respiratory Medicine, IPGMER, Kolkata over a period of 6 months.

Results: Obstructive airway diseases were found in 50% patients, pneumonia in 38% of cases, lung cancer in 34%, tuberculosis in 10% and diffuse parenchymal lung diseases in 3% of cases. There were significant amount of atypical symptoms like history of fall, confusion and urinary incontinence. Pneumonia often presented without leukocytosis (40% cases) and presented with complications like septic shock (31.5%), respiratory failure (42.1%) and arrhythmia (39.5%). Presentations of tuberculosis were atypical in the form of diffuse bilateral mid-lower zones involvement and less cavitary lesions. Significant decrease of Barthel Index, indicative of morbidity, was seen especially in pneumonia and obstructive airway diseases; more than 40 decrease of Barthel Index in 49% of cases.

Conclusion: Presentations of respiratory disorders were often atypical and associated with multiple co-morbidities that contributed to significant impact on morbidity and mortality in elderly population presenting with respiratory diseases.

Congenital cystic adenomatoid malformation: A tertiary care hospital experience

Asmita Mehta, Mohan Abraham, Naveen Viswanath, Rajesh Venkitakrishnan, V. P. Gopinathan

Department of Pulmonary Medicine, AIMS Ponekkara, Kochi, Kerala, India. E-mail [email protected]

Introduction: Congenital cystic adenomatoid malformation (CCAM) is a rare developmental anomaly of the terminal respiratory structures with an incidence of 1 in 10,000-1 in 35,000 births. They are considered broncho pulmonary foregut malformations caused probably by an arrest in lung development between 4 th and 7 th week of fetal life.

Aim: To study clinical, radiological profile and role of surgical intervention in patients with CCAM.

Materials and Methods: All patients with clinical suspicion or provisional diagnosis of CCAM were included in the study. A standardized questionnaire was prepared to collect data. All patients had undergone computed tomography chest with HRCT. After confirmation of diagnosis, pediatric surgery opinion was obtained. They were subjected to procedures as per the consideration.

Results: Total 15 patients with diagnosis of CCAM were included in the study. Of them, 8 (53.3%) were male while the remaining were female. The commonest presentation was cough 13(86%) followed by sucking difficulty/breathing difficulty in 11(73%), fever in 9(60%), recurrent pneumonia in 4 (26%), acute respiratory distress syndrome in 6 (40%) and others in 2 (12%). Thirteen patients were subjected to surgical management in the form of lobectomy. There was no procedure related mortality and all were successfully discharged with a median duration of stay 11 ± 16 days.

Conclusion: Early recognition and surgical intervention of CCAM is essential to prevent the consequences of recurrent pulmonary infections and the potential risk for malignant transformation. Present study showed that lobectomy was a procedure with fewer complications. It required a short hospital stay and had good post-operative prognosis.


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