Kuruswamy Thurai Prasad

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations

Contents: Executive Summary Introduction Methodology Definition, Epidemiology and Risk Factors Diagnosis of Asthma Management of Stable Asthma Management of Acute Exacerbations of Asthma Miscellaneous Issues in Asthma Management

A Randomized Trial of Antimicrobial Prophylaxis in Patients Undergoing Medical Thoracoscopy (APT)

Background: There is no data on the role of prophylactic antibiotics in patients undergoing medical thoracoscopy. Objective: In this study, we evaluated the efficacy and safety of a single dose of intravenous cefazolin in subjects undergoing medical thoracoscopy. Methods: Subjects undergoing medical thoracoscopy were randomized 1:1 to receive either intravenous cefazolin 2 g (antibiotic group) or intravenous saline (control group). The primary outcome was the incidence of infections (surgical site infections and empyema) in the study groups, while the secondary outcomes were complications related to intravenous antibiotics. Results: Of the 121 subjects screened, 100 (mean age ± SD: 52.2 ± 15.2 years; 38 [38%] women) were randomized to the study groups. The incidence of postprocedural infections was not different between the antibiotic and the control group (4 [8%] vs. 6 [12%], p = 0.28). Surgical site infection occurred in 1 subject (2%) in the antibiotic group and 3 subjects (6%) in the saline group (p = 0.62); empyema occurred in 3 subjects (6%) in each group (p = 1.00). There was no association between age, comorbid illness (diabetes mellitus or chronic kidney disease), study group allocation, type of thoracoscope used, duration of procedure, histological diagnosis (benign or malignant), and the occurrence of infections in the postprocedural period. Conclusion: The use of a single dose of cefazolin prior to medical thoracoscopy was not associated with a reduction in the occurrence of postprocedural infection.

Endoscopic ultrasound (with an echobronchoscope)-guided fine-needle aspiration for diagnosis of a mediastinal lesion in a mechanically ventilated patient: A case report and systematic review of the literature

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is routinely used for accessing mediastinal lymph nodes and masses. However, in patients with respiratory failure, who are being mechanically ventilated through an endotracheal tube, EBUS-TBNA may not be feasible due to several reasons. In such patients, the esophageal route offers a useful alternative for accessing mediastinal lesions. Herein, we describe a 50-year-old man with a mediastinal mass, who was being invasively ventilated for respiratory failure. Endoscopic ultrasound (with an echobronchoscope)-guided fine-needle aspiration was performed, which revealed a diagnosis of small cell carcinoma. Appropriate cancer chemotherapy resulted in successful liberation of the patient from mechanical ventilation. We have also performed a systematic review of literature for reports of endoscopic diagnostic procedures for mediastinal/hilar lesions in critically ill patients.

A Randomized Trial Evaluating the Effect of 10 versus 20 Revolutions Inside the Lymph Node on the Diagnostic Yield of EBUS-TBNA in Subjects with Sarcoidosis

Background: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is the preferred modality for sampling intrathoracic lymph nodes in patients with suspected sarcoidosis. Whether the number of revolutions of the needle inside the lymph node while performing TBNA affects the diagnostic yield is unknown. Objectives: The aim of this paper was to compare the yield of different numbers of needle revolutions (10 vs. 20) during EBUS-TBNA in sarcoidosis. Methods: Consecutive subjects with a clinicoradiological suspicion of sarcoidosis were randomized 1: 1 to undergo EBUS-TBNA with either 10 (group 1) or 20 revolutions (group 2). The primary and secondary outcomes were the diagnostic yield and adequacy of aspirates, respectively. Other outcomes were procedure duration, gross blood contamination of the aspirates, and safety of the procedure. Results: Of the 171 subjects screened, 150 (mean age 43.5 years; 47.3% women) were randomized. A mean of 2.8 (group 1: 2.8, group 2: 2.7; p = 0.37) lymph nodes were sampled per subject with a mean of 2.1 passes per node in each group (p = 0.60). Among 133 subjects finally diagnosed with sarcoidosis, there was no difference (p = 0.65) in the diagnostic yield of EBUS-TBNA between group 1 (52/65, 80.0%) and group 2 (57/68, 83.8%). Adequate aspirates were obtained in 96.9 and 97.1% of the subjects in groups 1 and 2, respectively (p = 1.00). There was no difference in the procedure duration, the proportion of subjects with grossly bloody specimens, or complications between the 2 groups. Conclusions: The diagnostic yield and specimen adequacy were not different when EBUS-TBNA was performed with 10 or 20 revolutions in subjects with sarcoidosis.

Spectrum of interstitial lung diseases at a tertiary center in a developing country: A study of 803 subjects

Background The spectrum of interstitial lung diseases (ILDs) have mainly been reported from the developed countries; data from developing countries is sparse and conflicting. The aim of this study is to describe the distribution of various ILDs from a developing country. Methods This is an analysis of prospectively collected clinical, radiological and histological data of consecutive subjects (age >12 years) with ILDs from a single tertiary care medical center. The diagnosis of the specific subtype of ILD was made according to standard criteria for various ILDs. Results A total of 803 subjects (mean age, 50.6 years; 50.2% women) were enrolled between March 2015 to February 2017 of which 566 (70.5%) were diagnosed during the study period (incident cases). Sarcoidosis (42.2%), idiopathic pulmonary fibrosis (IPF, 21.2%), connective tissue disease (CTD)-related ILDs (12.7%), hypersensitivity pneumonitis (10.7%), and non-IPF idiopathic interstitial pneumonias (9.2%) were the most common ILDs. The spectrum of ILDs was not significantly different (p = 0.87) between incident and prevalent cases. A histopathological specimen was obtained in 49.9% of the subjects yielding a histologically confirmed diagnosis in 40.6%. A diagnostic procedure was not performed in 402 subjects; the most common reasons were presence of definite usual interstitial pneumonia pattern on high resolution computed tomography and patients’ unwillingness to undergo the procedure. Conclusion Sarcoidosis, IPF and CTD-ILDs were the most common ILDs seen at a tertiary center in northern India similar to the spectrum reported from developed countries. More studies are required from developing countries to ascertain the spectrum of ILDs in different geographic locales.

Patient characteristics and outcome of end-stage lung diseases referred for lung transplantation in North India

Objective: Most countries worldwide have transplant registries for patients with end-stage lung diseases (ESLD) requiring lung transplantation. There is no such lung transplant registry in India. Herein, we describe the demographic profile and clinical outcomes among patients referred for lung transplantation at a tertiary care center in North India. Materials and Methods: This was a prospective, observational study of consecutive patients with chronic respiratory diseases who were referred for lung transplantation between July 2013 and December 2016. Patients were evaluated using standard criteria for listing for lung transplantation. Results: Of the 176 patients assessed for lung transplantation, 167 were included in the study. The mean (standard deviation [SD]) age of the study population (52.1% females) was 53.2 (14.7) years. Interstitial lung disease (ILD, 46.7%), chronic obstructive pulmonary disease (COPD, 25.7%), and bronchiectasis (10.2%) were the most common diseases in this population. The median (interquartile range, IQR) survival was worst for patients with bronchiolitis (78.5 [9–208] days) and idiopathic pulmonary fibrosis (IPF, 93.5 [19–239] days) and best for patients with idiopathic pulmonary arterial hypertension (757 [340–876] days) and COPD (578 [184–763] days). Only 13% of the patients expressed willingness for lung transplantation. Patients willing for transplantation died earlier than those unwilling (median [IQR], 102 [36-224] days vs. 310 [41-713] days, P < 0.001). Conclusion: ILD was the most common cause of ESLD in patients referred for lung transplantation. The waitlist mortality was highest for patients with bronchiolitis and IPF. Despite having ESLD, very few patients were willing for lung transplantation. Patients willing for lung transplantation died earlier than those who were unwilling.

Profile of patients with active tuberculosis admitted to a respiratory intensive care unit in a tertiary care center of North India

Background: There is a paucity of literature regarding outcome of critically ill patients with tuberculosis (TB) from India. Herein, we describe our experience of patients with active TB admitted to a Respiratory Intensive Care Unit (RICU) of a tertiary care hospital. Methods: This was a retrospective analysis of all the patients admitted with active TB. The baseline clinical, demographic, ICU parameters and mortality were recorded. A multivariate logistic regression analysis was performed to identify factors predicting mortality. Results: A total 3630 patients were admitted to the ICU during the study period; of these, 63 (1.7%) patients (mean [standard deviation (SD)] age 37.3 [19] years, 55.6% females) were admitted with active TB. Fifty-seven patients were mechanically ventilated (56, invasive and 1, noninvasive) for a mean (SD) duration of 7.5 (9.1) days. Respiratory failure was the most common indication for mechanical ventilation. TB-related acute respiratory distress syndrome was seen in 18 (28.6%) patients. There were 28 deaths (44.4%) during the study period. On a multivariate logistic regression analysis, a high baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) score (odds ratio [OR] [95 confidence interval (CI)], 1.12 [1.02–1.23]) and delta Sequential Organ Failure Assessment (SOFA) (OR [95 CI], 1.39 [1.00–1.94]) were the independent predictors of mortality. Conclusion: TB was an uncommon cause of ICU admission even in a high TB burden country. Critically ill patients with TB had high mortality. A higher APACHE II score and delta SOFA were independent predictors of ICU mortality.

Titration of ideal positive end-expiratory pressure in acute respiratory distress syndrome: Comparison between lower inflection point and esophageal pressure method using volumetric capnography

The tenets of mechanical ventilation in acute respiratory distress syndrome (ARDS) include the utilization of low tidal volume and optimal application of positive end-expiratory pressure (PEEP). Optimal PEEP in ARDS is characterized by reduction in alveolar dead space along with improvement in the lung compliance and resultant betterment in oxygenation. There are various methods of setting PEEP in ARDS. Herein, we report a patient of ARDS, wherein we employed measurement of dead space using volumetric capnography to compare two different PEEP strategies, namely, the lower inflection point and transpulmonary pressure monitoring.

Complete subglottic tracheal stenosis managed with rigid bronchoscopy and T-tube placement

Surgery is the preferred treatment modality for benign tracheal stenosis. Interventional bronchoscopy is used as a bridge to surgery or in instances when surgery is not feasible or has failed. Stenosis in the subglottic trachea is particularly a treatment challenge, in view of its proximity to the vocal cords. Herein, we describe a patient with complete tracheal stenosis in the subglottic region, which developed after prolonged intubation and mechanical ventilation. The patient developed recurrent stenosis despite multiple surgical and endoscopic procedures. We were able to manage the patient successfully with rigid bronchoscopy and Montgomery T-tube placement.