Raja Dhar

Interstitial Lung Disease in India. Results of a Prospective Registry

Rationale: Interstitial lung disease (ILD) is a heterogeneous group of acute and chronic inflammatory and fibrotic lung diseases. Existing ILD registries have had variable findings. Little is known about the clinical profile of ILDs in India. Objectives: To characterize new‐onset ILDs in India by creating a prospective ILD using multidisciplinary discussion (MDD) to validate diagnoses. Methods: Adult patients of Indian origin living in India with new‐onset ILD (27 centers, 19 Indian cities, March 2012‐June 2015) without malignancy or infection were included. All had connective tissue disease (CTD) serologies, spirometry, and high‐resolution computed tomography chest. ILD pattern was defined by high‐resolution computed tomography images. Three groups independently made diagnoses after review of clinical data including that from prompted case report forms: local site investigators, ILD experts at the National Data Coordinating Center (NDCC; Jaipur, India) with MDD, and experienced ILD experts at the Center for ILD (CILD; Seattle, WA) with MDD. Cohens &kgr; was used to assess reliability of interobserver agreement. Measurements and Main Results: A total of 1,084 patients were recruited. Final diagnosis: hypersensitivity pneumonitis in 47.3% (n = 513; exposure, 48.1% air coolers), CTD‐ILD in 13.9%, and idiopathic pulmonary fibrosis in 13.7%. Cohens &kgr;: 0.351 site investigator/CILD, 0.519 site investigator/NDCC, and 0.618 NDCC/CILD. Conclusions: Hypersensitivity pneumonitis was the most common new‐onset ILD in India, followed by CTD‐ILD and idiopathic pulmonary fibrosis; diagnoses varied between site investigators and CILD experts, emphasizing the value of MDD in ILD diagnosis. Prompted case report forms including environmental exposures in prospective registries will likely provide further insight into the etiology and management of ILD worldwide.

Global impact of bronchiectasis and cystic fibrosis

Educational aims To recognise the clinical and radiological presentation of the spectrum of diseases associated with bronchiectasis. To understand variation in the aetiology, microbiology and burden of bronchiectasis and cystic fibrosis across different global healthcare systems. Bronchiectasis is the term used to refer to dilatation of the bronchi that is usually permanent and is associated with a clinical syndrome of cough, sputum production and recurrent respiratory infections. It can be caused by a range of inherited and acquired disorders, or may be idiopathic in nature. The most well recognised inherited disorder in Western countries is cystic fibrosis (CF), an autosomal recessive condition that leads to progressive bronchiectasis, bacterial infection and premature mortality. Both bronchiectasis due to CF and bronchiectasis due to other conditions are placing an increasing burden on healthcare systems internationally. Treatments for CF are becoming more effective leading to more adult patients with complex healthcare needs. Bronchiectasis not due to CF is becoming increasingly recognised, particularly in the elderly population. Recognition is important and can lead to identification of the underlying cause, appropriate treatment and improved quality of life. The disease is highly diverse in its presentation, requiring all respiratory physicians to have knowledge of the different “bronchiectasis syndromes”. The most common aetiologies and presenting syndromes vary depending on geography, with nontuberculous mycobacterial disease predominating in some parts of North America, post-infectious and idiopathic disease predominating in Western Europe, and post-tuberculosis bronchiectasis dominating in South Asia and Eastern Europe. Ongoing global collaborative studies will greatly advance our understanding of the international impact of bronchiectasis and CF. Bronchiectasis and CF: disabling diseases with a growing impact worldwide http://ow.ly/U0S0302ocv3

The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC): experiences from a successful ERS Clinical Research Collaboration

In contrast to airway diseases like chronic obstructive pulmonary disease or asthma, and rare diseases such as cystic fibrosis, there has been little research and few clinical trials in bronchiectasis. Guidelines are primarily based on expert opinion and treatment is challenging because of the heterogeneous nature of the disease. In an effort to address decades of underinvestment in bronchiectasis research, education and clinical care, the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) was established in 2012 as a collaborative pan-European network to bring together bronchiectasis researchers. The European Respiratory Society officially funded EMBARC in 2013 as a Clinical Research Collaboration, providing support and infrastructure to allow the project to grow. EMBARC has now established an international bronchiectasis registry that is active in more than 30 countries both within and outside Europe. Beyond the registry, the network participates in designing and facilitating clinical trials, has set international research priorities, promotes education and has participated in producing the first international bronchiectasis guidelines. This manuscript article the development, structure and achievements of EMBARC from 2012 to 2017. Educational aims To understand the role of Clinical Research Collaborations as the major way in which the European Respiratory Society can stimulate clinical research in different disease areas To understand some of the key features of successful disease registries To review key epidemiological, clinical and translational studies of bronchiectasis contributed by the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) project in the past 5 years To understand the key research priorities identified by EMBARC for the next 5 years Learn about @EMBARCnetwork, a successful @ERStalk Clinical Research Collaboration with @EuropeanLung http://ow.ly/IOl230drGf1

Salmeterol/fluticasone through breath-actuated inhaler versus pMDI: a randomized, double-blind, 12 weeks study

Abstract Objective: Salmeterol/fluticasone combination (SFC) formulated in a breath-actuated inhaler (BAI) overcomes the co-ordination problem associated with the pressurized-metered dose inhaler (pMDIs). Our aim was to compare the efficacy and the safety of SFC given through the BAI versus the conventional pMDI in moderate-to-severe asthmatics. Methods: In this randomized, double-blind, double-dummy, prospective, active-controlled, parallel group, multicenter, 12 weeks study, 150 asthmatics were randomized to receive SFC (25/125 mcg) through either BAI or pMDI. The primary efficacy endpoint was mean change in pre-dose morning PEFR value at 12 weeks and the secondary efficacy endpoints included, mean change in FEV1, pre-bronchodilator FVC, pre-dose morning and evening PEFR, symptom scores at 2, 4, 8, and 12 weeks. Patient preferences for device and safety were also assessed. Results: At 12 weeks, the mean change in pre-dose morning PEFR in BAI and pMDI groups was 50.72 L/min and 48.82 L/min, respectively (p < 0.0001; both groups) and the difference between the two groups was not significant. Both the treatment groups showed a statistically significant improvement in secondary endpoints at all-time points compared with baseline. The usability questionnaire assessment results showed that the BAI device was preferred by 75% of patients as compared with 25% preferring pMDI. SFC in both BAI and pMDI devices was found to be safe and well tolerated. Conclusion: This is the first study to demonstrate that SFC given through the BAI produces comparable efficacy and safety endpoints as pMDI. Additionally, BAI was the preferred inhaler by patients compared to conventional pMDI.

Reference equation for spirometry interpretation for Eastern India

Introduction: Spirometry measurements are interpreted by comparing with reference values for healthy individuals that have been derived from multiple regression equations from earlier studies. There are only two such studies from Eastern India, both by Chatterjee et al., one each for males and females. These are however single center and approximately two decades old studies. Aims: (1) to formulate a new regression equation for predicting FEV 1 and FVC for eastern India and (2) to compare the results to the previous two studies by Chatterjee et al. Materials and Methods: Healthy nonsmokers were recruited through health camps under the initiative of four large hospitals of Kolkata. Predicted equations were derived for FEV 1 , FVC and FEV 1 /FVC in males and females separately using multiple linear regression, which were then compared with the older equations using Bland-Altman method. Results: The Bland-Altman analyses show that the mean bias for females for FVC was 0.39 L (95% limits of agreement 1.32 to −0.54 L) and for FEV1 was 0.334 L (95% limits of agreement of 1.08 to -0.41 L). For males the mean bias for FEV1 was -0.141 L, (95% limits of agreement 0.88 to -1.16 L) while that for FVC was -0.112 L (95% limits of agreement 0.80 to -1.08 L). Conclusion: New updated regression equations are needed for predicting reference values for spirometry interpretation. The regression equations proposed in this study may be considered appropriate for use in current practice for eastern India until further studies are available.

Factors influencing severity of community-acquired pneumonia

Introduction: Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in India. There is a need to understand the risk factors associated with severity of CAP in our population. This study was part of the international global initiative for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia study to evaluate MRSA. Methods: A total of 100 consecutive cases of pneumonia admitted to the Department of Pulmonary Medicine in a tertiary care hospital were recruited in the study during March–July 2015. The severity of pneumonia was assessed based on the CURB-65 score. Individuals with pneumonia and CURB-65 score >2 were compared with subjects with CURB-65 score ≤2. Individuals were also evaluated for the causative organism and its resistance pattern with specific reference to the presence of MRSA. Results: Mean age of patients was 54.03 years, 66% were men. Patients were managed either in the intensive care unit (42%) or wards/high dependency unit (58%), 22% needed noninvasive ventilation and 18% needed mechanical ventilation within 24 h of admission. On multivariate analysis, prior respiratory infection (within last 1 year), obesity (body mass index >30), and alcoholism, old age (>60 years) were independently associated risk factors for severe pneumonia. There were no cases of MRSA. In 34% of cases, organisms could be identified. Most common organisms were Klebsiella (8%), influenza (8%), and Pseudomonas (5%). Conclusion: Prior respiratory infection, obesity, alcoholism, and old age (>60 years) were observed to be important risk factors for severe CAP. Prospective studies should evaluate effect of weight reduction and cessation of alcohol consumption on recurrences of pneumonia in this population and on the severity of pneumonia.

Additional important research priorities for bronchiectasis in China

We thank W. Guan and colleagues for highlighting important additional research priorities for bronchiectasis in China. The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) research priorities “roadmap” published in the European Respiratory Journal was specifically developed to address the issue of research priorities from the point of view of European experts, and with this in mind, it is important to consider how these priorities may be different across different healthcare systems in differing areas of the world [1]. A new international consortium of bronchiectasis researchers has been launched http://ow.ly/HfK4307adkV

Nontuberculous mycobacterial diseases: Current diagnosis and treatment

There has been an ever-expanding list of isolation of organisms in the genus Mycobacterium. Leprosy and tuberculosis are specific diseases caused by mycobacteria; there are now several other mycobacteria that cause human diseases and can be widely found in the environment. These other mycobacteria are called as nontuberculous mycobacteria (NTM) or mycobacteria other than tubercle bacilli (MOTT) or atypical mycobacteria. They cause various human infections in the lungs, lymph glands, skin, wounds, or bone. They may also produce disseminated disease, especially in the immunocompromised. Various molecular, biochemical, and chemical techniques have been developed for rapid identification of these species. While it might be difficult to treat these infections, with duration of treatment longer than that for tuberculosis or leprosy, many drugs such as rifampicin, rifabutin, ethambutol, clofazimine, amikacin, new generation quinolones, and macrolides effective against mycobacterial infections are available that can be used in appropriate combinations and dosage to treat the NTM.

Noninvasive ventilation in hypoxemic respiratory failure

Noninvasive ventilation (NIV) refers to positive pressure ventilation delivered through a noninvasive interface (nasal mask, facemask, or nasal plugs) etc. Over the past decade its use has become more common as its benefits are increasingly recognized. This review will focus on the evidence supporting the use of NIV in various conditions resulting in acute hypoxemic respiratory failure (AHRF), that is, non-hypercapnic patients having acute respiratory failure in the absence of a cardiac origin or underlying chronic pulmonary disease. Outcomes depend on the patients diagnosis and clinical characteristics. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced team, with careful patient selection, should optimize patient outcomes.