Gc Khilnani

Corticosteroids and ARDS: A review of treatment and prevention evidence.

To systematically review the role of corticosteroids in prevention of acute respiratory distress syndrome (ARDS) in high-risk patients, and in treatment of established ARDS. Primary articles were identified by English-language Pubmed/MEDLINE, Cochrane central register of controlled trials, and Cochrane systemic review database search (1960–June 2009) using the MeSH headings: ARDS, adult respiratory distress syndrome, ARDS, corticosteroids, and methylprednisolone (MP). The identified studies were reviewed and information regarding role of corticosteroids in prevention and treatment of ARDS was evaluated. Nine trials have evaluated the role of corticosteroid drugs in management of ARDS at various stages. Of the 9, 4 trials evaluated role of corticosteroids in prevention of ARDS, while other 5 trials were focused on treatment after variable periods of onset of ARDS. Trials with preventive corticosteroids, mostly using high doses of MP, showed negative results with patients in treatment arm, showing higher mortality and rate of ARDS development. While trials of corticosteroids in early ARDS showed variable results, somewhat, favoring use of these agents to reduce associated morbidities. In late stage of ARDS, these drugs have no benefits and are associated with adverse outcome. Use of corticosteroids in patients with early ARDS showed equivocal results in decreasing mortality; however, there is evidence that these drugs reduce organ dysfunction score, lung injury score, ventilator requirement, and intensive care unit stay. However, most of these trials are small, having a significant heterogeneity regarding study design, etiology of ARDS, and dosage of corticosteroids. Further research involving large-scale trials on relatively homogeneous cohort is necessary to establish the role of corticosteroids for this condition.

Comparison of bronchoscopic and non-bronchoscopic techniques for diagnosis of ventilator associated pneumonia

Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6–99.7], 57.1% (CI: 13.4–86.1), 85% (CI: 61.1–96) and 80% (CI: 21.9–98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9–92.6), 71.8% (CI: 24.1–94), 87.3% (CI: 60.4–97.8) and 55.5% (CI: 17.4–82.6), respectively. Sensitivity, specificity, PPV and NPV for non–bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7–95.6), 71.43% (CI: 24.1–94), 88.2% (CI: 62.3–97.4) and 62.5% (CI: 20.2–88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (κ-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.

A study of empyema thoracis and role of intrapleural streptokinase in its management

BackgroundClinical spectrum, microbiology and outcome of empyema thoracis are changing. Intrapleural instillation of fibrinolytic agents is being increasingly used for management of empyema thoracis. The present study was carried out to describe the clinical profile and outcome of patients with empyema thoracis including those with chronic empyema and to study the efficacy and safety of intrapleural streptokinase in its management.MethodsClinical profile, etiological agents, hospital course and outcome of 31 patients (mean age 40 ± 16 years, M: F 25: 6) with empyema thoracis treated from 1998 to 2003 was analyzed. All patients were diagnosed on the basis of aspiration of frank pus from pleural cavity. Clinical profile, response to therapy and outcome were compared between the patients who received intrapleural streptokinase (n = 12) and those who did not (n = 19).ResultsEtiology was tubercular in 42% of the patients (n = 13) whereas the rest were bacterial. Amongst the patients in which organisms could be isolated (n = 13, 42%) Staphylococcus aureus was the commonest (n = 5). Intrapleural streptokinase was instilled in 12 patients. This procedure resulted in increase of drainage of pleural fluid in all patients. Mean daily pleural fluid drainage after streptokinase instillation was significantly higher for patients who received intrapleural streptokinase than those who did not (213 ml vs 57 ml, p = 0.006). Only one patient who was instilled streptokinase eventually required decortication, which had to be done in five patients (16.1%). Mean hospital stay was 30.2 ± 17.6 days whereas two patients died.ConclusionsTubercular empyema is common in Indian patients. Intrapleural streptokinase appears to be a useful strategy to preserve lung function and reduce need for surgery in patients with late stage of empyema thoracis.

Utility of conventional transbronchial needle aspiration with rapid on-site evaluation (c-TBNA-ROSE) at a tertiary care center with endobronchial ultrasound (EBUS) facility

Background: Conventional transbronchial needle aspiration (c-TBNA) is an underutilized bronchoscopic modality. Endobronchial ultrasound (EBUS) guided-TBNA though efficacious is an expensive modality, facilities of which are available at only limited centers. c-TBNA is cost-effective and has potential for wide utilization especially in resource-limited settings. Rapid on-site evaluation (ROSE) improves the yield of c-TBNA. Materials and Methods: A retrospective review of the bronchoscopy records (May 2012 to July 2014) was performed. The patients who underwent c-TBNA with ROSE were included in the study and their clinical details were extracted. Convex probe EBUS-TBNA was being regularly performed during the study period by the operators performing c-TBNA. Results: c-TBNA with ROSE was performed in 41 patients with mean age of 42.4 (16.2) years. The most frequently sampled node stations (>90% patients) were the subcarinal and lower right paratracheal. Representative samples could be obtained in 33 out of the 41 patients (80.4%). c-TBNA was diagnostic in 32 [tuberculosis (TB)-8, sarcoidosis-9, and malignancy-15] patients out of the 41 patients. The overall diagnostic yield (sensitivity) of c-TBNA with ROSE was 78%. Mean procedure duration was 18.4 (3.1) min and there were no procedural complications. Conclusion: c-TBNA with ROSE is a safe, efficacious, and cost-effective bronchoscopic modality. When it was performed by operators routinely performing EBUS-TBNA, diagnostic yields similar to that of EBUS-TBNA can be obtained. Even at the centers where EBUS facilities are available, c-TBNA should be routinely performed.

Fractional exhaled nitric oxide is a useful adjunctive modality for monitoring bronchial asthma

Background and Objective: To evaluate the utility of fractional exhaled nitric oxide (FeNO) in monitoring asthma control. Materials and Methods: Steroid naïve nonsmoking asthmatics were recruited and followed for 6–8 weeks on standard treatment. Serial measurements of FeNO, peak expiratory flow rate (PEFR) variability, forced expiratory volume in 1 s (FEV1), bronchodilator reversibility (BDR), and asthma control test (ACT) score were measured at baseline and after 6–8 weeks of treatment. Results: One hundred and fifty-one patients were recruited over an 18-month period. These comprised 79 males (52.3%) with mean (standard deviation) age of 34.2 (11.6). Mean (SD) FeNO levels at baseline and after therapy were 45.4 (35.9) and 38.4 (23.7) ppb, respectively (P = 0.01). Baseline FeNO correlated strongly with FEV1 (r = −0.78, P < 0.001), ACT score (r = −0.76, P < 0.001), PEFR variability (r = −0.74, P < 0.001), and moderately with BDR (r = 0.50, P < 0.001). After treatment with inhaled steroids, the correlation remained strong with ACT score (r = −0.68, P < 0.001) but weakened with PEFR variability (r = −0.34, P = 0.01) and FEV1 (r = −0.36, P = 0.01). Conclusions: FeNO may be useful as an adjunctive noninvasive modality to assess asthma control in both steroid naïve asthmatics and asthmatics on treatment. However, the suboptimal sensitivity and specificity may limit its utility as a point-of-care single monitoring tool.

An Enlarging Airway Foreign Body

A 25-year-old female patient presented with dry coughs of 20 days duration and fever for four days. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the thorax revealed endobronchial opacity in the right main bronchus suggestive of a foreign body. Patient retrospectively recollected history of betel nut aspiration just prior to onset of symptoms. Flexible bronchoscopy revealed a large sized blackishbrownish large foreign body (betel nut) in the right main bronchus which was successfully removed using the flexible bronchoscope itself. Due to the hygroscopic character of betel nut, it had absorbed moisture and had considerably increased in size. Although rigid bronchoscope is the preferable modality for removal of large sized airway foreign bodies, flexible bronchoscope is especially useful and often preferable as it obviates the need for general anesthesia. On examination, blood pressure (100/78mmHg), pulse rate (94/ min) and respiratory rate (22/min) were normal. Examination of chest revealed no significant abnormality. Other systemic examination was also unremarkable. Posteroanterior radiograph of chest was normal (Figure 1). In view of persistent symptoms, CT scan examination of the thorax was (Figure 2) done. It revealed endobronchial opacity in the right main bronchus suggestive of a foreign body which was almost completely occluding the lumen of the right main bronchus. Hyperlucency of the right lung fields was also observed suggestive of post obstructive hyperinflation. The opacity looked well defined and did not appear to arise from the wall of the bronchus. Patient’s history was reviewed again and she recollected that on the night prior to onset of symptom, she was chewing a betel nut and while laughing on a joke during conversation she had likely aspirated it. With a diagnosis of FB aspiration in the right main bronchus, Background

Ventilator-Associated pneumonia: Changing microbiology and implications

Access this article online Website: www.ijccm.org DOI: 10.4103/0972-5229.123432 Quick Response Code: Ventilator-associated pneumonia (VAP) is the most important nosocomial infection among mechanically ventilated patients and the biggest worry of critical care physicians. Though the incidence of VAP has declined in the developed countries, it continues to be unacceptably high in the developing world.[1] Its incidence in these countries is 20 times that in the developed nations with signifi cant morbidity, mortality, and enhanced cost of care. In a study by Joseph et al. in 2009, the incidence of VAP was found to be 30.67 and 15.87 per 1000 ventilator days in two different ICUs.[2] These differences in incidence depend upon the antibiotic profi le, ICU environment, and the study population. High incidence of VAP points towards insuffi cient preventive strategies and probably inappropriate antibiotics administration. Organisms for VAP are different in different part of world and also in different ICUs in the same hospital. The most common organisms for early VAP are community pathogens such as Streptococcus pneumoniae, Hemophilus influenzae, and Methicillin-sensitive Staphylococcus aureus. However, in developing countries, the spectrum is changing and drug-resistant organisms and hospitalacquired pathogens are becoming more common. This may be due to excessive use of broad spectrum antibiotics early in intensive care. Also, more often, gram-negative organisms are the causative pathogens, which are usually multi-drug-resistant.[3,4] Since microbiology and resistance pattern in India is different from other countries, there is need for data from our country to choose appropriate antimicrobials for management. Moreover, several risk factors predispose these patients to either colonization of respiratory tract or aspiration of secretions. Knowledge of these risk factors for VAP can be utilized to plan effi cient preventive measures. In this issue, Saravu and collegues[5] have studied determinants of VAP and its impact on prognosis. They also analyzed the microbiological data and its implications on mortality in 52 patients with VAP and controls and found that prior use of steroids, reintubation, and bacteremia were significantly associated with the occurrence of VAP. The importance of these determinants lies in the fact that these are potentially modifiable factors. Late-onset VAP was almost as common as early-onset VAP, which is an interesting observation. Most common organisms isolated were Acinetobacter Pseudomonas, Klebsiella, and Staphylococcus Aureus. Acinetobacter is the emerging drug-resistant pathogen both in cases with early as well as late VAP. Majority of the pathogens were multi-drug-resistant, and a signifi cant number of organisms were resistant even to infrequently used antibiotics like Colistin and Polymixin, which is a worrying situation both in terms of cost of care and mortality. The frequent community -acquired pathogens causing early VAP elsewhere in world is not grown in the cultures at all.

Noninvasive ventilation–neurally adjusted ventilator assist for management of acute exacerbation of chronic obstructive pulmonary disease

Patient–ventilator asynchrony is common with noninvasive ventilation (NIV) used for management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Neurally adjusted ventilator assist (NAVA) is a mode of ventilatory support which can minimize the patient–ventilator asynchrony. Delivering NIV with NAVA (NIV–NAVA) during acute exacerbation of COPD seems a logical approach and may be useful in reducing patient–ventilator asynchrony. However, there are no published reports which describe the use of NIV–NAVA for management of acute exacerbation of COPD. We describe the successful management of a 56-year-old gentleman presenting to the emergency department of our hospital with acute exacerbation of COPD with hypercapnic respiratory failure with NIV–NAVA.

A 44-year-old man with hemoptysis

A 44-year-old man with background history of diffuse cutaneous systemic sclerosis and dilated cardiomyopathy receiving immunosuppressive medications, presented with a 2-month history of cough and streaky hemoptysis. Clinicoradiological features were consistent with an endotracheal mass. Subsequently, the patient developed nodular skin lesions and the tracheal mass increased in size causing central airway obstruction. This clinicopathologic conference discusses the clinical and radiological differential diagnoses of such a clinical presentation and their management options.

54P Epidermal growth factor receptor expression (EGFR) in serum as a marker of treatment response and survival in advanced squamous cell lung cancer

were detected in 37 pts, most of which occurred in tyrosine kinase domain (Ex19del, 42%; L858R, 37%). Most EGFR mutation were clonal in tissue and plasma, with a consistence of 85% in paired samples. In addition, bTMB was significantly correlated to tTMB (Pearson r = 0.75, p-value = 2.3e-12), with a consistence of 90%. Interestingly, high TMB was observed in a small fraction of patients (6%) with driver mutations, such as mutations in EGFR, ALK fusion, ERBB2 and PIK3CA. Conclusions:Deep sequencingwith the pan-cancer panel can effectively detect mutations and evaluate TMB in both tissue and blood with high consistence. EGFR mutations can be clonal or subclonal in both tissue and blood. Prospective multicenter study is ongoing to determine the EGFR clonality as a predictive factor for the TKI efficacy in NSCLC (TRACELib-NSCLC). Clinical trial identification: NCT03059641 Legal entity responsible for the study: Shanghai Chest Hospital Funding: Geneplus-Beijing Institute Disclosure: All authors have declared no conflicts of interest.