Valliappan Muthu

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 report of a successfully treated case of ABPA in an HIV-infected individual.

Aspergillus fumigatus is a ubiquitous fungus responsible for a variety of pulmonary diseases, ranging from infection of a pre-existing cavity as in aspergilloma to highly invasive disease in immunocompromised hosts. Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity response mounted against antigens of A. fumigatus manifesting as poorly controlled asthma and bronchiectasis. Although ABPA is not uncommon, occurrence of ABPA in HIV-affected individuals is distinctly rare. We describe the occurrence of ABPA in a 35-year-old woman with poorly controlled asthma since childhood and HIV-1 infection of 11 years duration. This is the second documented case of ABPA in a HIV-affected individual, and the first reported case to be successfully managed with antifungal therapy alone. We also discuss the complex management issues involved in treating ABPA in HIV-affected individuals.

Pulmonary Gangrene Due to Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and Probable Sarcina Organisms.

Pulmonary gangrene is a life-threatening condition, which represents the fulminant end of the infectious lung diseases usually caused by polymicrobial infection. Aerobic and anaerobic bacteria act synergistically to produce massive tissue necrosis which might be augmented by the angioinvasive nature of fungi like Mucor. We report a successfully treated case of pulmonary gangrene in a poorly controlled diabetic patient, which was associated with polymicrobial infection. It was caused by Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and unusual anaerobic organism Sarcina. This is the first report describing the presence of Sarcina organisms in a case of pulmonary gangrene. Adequate glycemic control, treatment of coexisting polymicrobial infection and prompt antifungal therapy along with surgical intervention were useful in the index patient. This case also highlights the effectiveness of combined medical and surgical intervention in a case of pulmonary gangrene.

An unusual cause of posterior mediastinal cyst

Cystic lesions of the mediastinum may be congenital or acquired. The differential diagnosis depends on their location in the mediastinum. Cysts in the posterior mediastinum are generally developmental cysts and are neurogenic or of foregut origin. We report the case of a 14-year-old boy, who presented with dry cough and progressively increasing breathlessness, and was found to have a cystic lesion in the posterior mediastinum. Fine needle aspiration from the cyst helped make a diagnosis of tuberculosis.

Efficacy of endosonographic procedures in mediastinal re-staging of lung cancer after neoadjuvant therapy: A systematic review and diagnostic accuracy meta-analysis

BACKGROUND: The optimal modality for restaging the mediastinum following neoadjuvant therapy for lung cancer remains unclear. Surgical methods are currently considered the reference standard. The present study evaluates the role of endosonographic techniques for mediastinal restaging in lung cancer. METHODS: A systematic review of PubMed and Embase databases was performed to identify studies using endoscopic ultrasound, endobronchial ultrasound, or a combination of the two for mediastinal restaging following induction therapy for stage III lung cancer. The quality of the included studies was assessed by using the Quality Assessment of Diagnostic Accuracy Studies–2 tool. The accuracy of endosonography was analyzed by calculating the sensitivity, specificity, likelihood ratio, and diagnostic OR for each study and pooling the results by using a bivariate model. Heterogeneity and publication bias were assessed. Potential causes of heterogeneity were explored by using sensitivity analysis and meta‐regression. RESULTS: Ten studies (N = 574) were included. The pooled sensitivity, specificity, diagnostic OR, and positive and negative likelihood ratios were 67% (95% CI, 56–77), 99% (95% CI, 89–100), 157, 52.0, and 0.33, respectively. No complications were reported. Significant heterogeneity was observed for the outcome of sensitivity. Sensitivity analysis identified several factors accounting for heterogeneity, including study design and risk of bias. The sensitivity of the endosonographic procedure was also linked to the prevalence of N2 disease on meta‐regression. Funnel plot showed publication bias, but this finding was not evident on statistical tests. CONCLUSIONS: Endosonographic procedures are safe and highly specific in mediastinal restaging of lung cancer.

‘Permissive’ hypercapnia in ARDS: is it passé?

Initial correspondence from Drs. Muthu, Agarwal and Sehgal Recently, Nin et al. demonstrated that hypercapnia was associated with a higher likelihood of intensive care unit (ICU) mortality in subjects with acute respiratory distress syndrome (ARDS) [1]. In order to investigate the effect of PaCO2 in our ICU population, we collected the demographic and clinical information of 415 subjects with ARDS admitted between 1 January 2001 and 31 December 2016. On a multivariate logistic regression analysis, baseline APACHE II, baseline pH and severity of ARDS were predictors of mortality, but the worst PaCO2 values during the initial 48 h were not (Table 1). Contrary to Nin et al., PaCO2 levels did not predict mortality in our cohort. Most importantly, Nin et al. did not adjust for severity of ARDS in their study population. There is increase in the odds of death with increasing severity of ARDS (also highlighted in our study). Also, if PaCO2 was associated with a higher mortality, the authors should have also adjusted for the baseline PaCO2 levels rather than the values during 48 h after ventilation as a covariate. A high PaCO2 level after ventilation could merely be a reflection of severe ARDS, as those with severe lung injury are more likely to be ventilated with lower tidal volume (less than 6 mL/kg body weight). Moreover, it is the pH and not the PaCO2 that is mechanistically associated with poorer outcomes as seen in our study cohort [2]. Finally, Nin et al. have not adjusted for lung compliance that reflects severity of lung damage, which also could affect the overall survival [3]. In conclusion, it is the severity of ARDS and pH values rather than the PaCO2 levels alone that predicts mortality.

Acute Respiratory Distress Syndrome Due To Tuberculosis in a Respiratory Icu Over a 16-year Period

Objective: Whether tuberculosis-related acute respiratory distress syndrome is associated with worse outcomes when compared with acute respiratory distress syndrome secondary to other causes remains unknown. Herein, we compare the outcomes between the two groups. Design: Retrospective analysis of all subjects admitted with acute respiratory distress syndrome over the last 16 years. Setting: Respiratory ICU of a tertiary care hospital in North India. Subjects: Consecutive subjects with acute respiratory distress syndrome. Intervention: Subjects were categorized as tuberculosis-related acute respiratory distress syndrome and acute respiratory distress syndrome-others and were managed with mechanical ventilation using the low tidal volume strategy as per the Acute Respiratory Distress Syndrom Network protocol. Measurements and Main Results: The baseline clinical and demographic characteristics, lung mechanics, and mortality were compared between the two groups. Factors predicting ICU survival were analyzed using multivariate logistic regression analysis. During the study period, 469 patients (18 tuberculosis-related acute respiratory distress syndrome and 451 acute respiratory distress syndrome-others) with acute respiratory distress syndrome were admitted. The mean (SD) age of the study population (52.9% women) was 33.6 years (14.8 yr). The baseline parameters and the lung mechanics were similar between the two groups. There were 132 deaths (28.1%) with no difference between the two groups (tuberculosis-related acute respiratory distress syndrome vs acute respiratory distress syndrome-others; 27.7% vs 28.2%; p = 0.71). There was also no significant difference in the ventilator-free days, ICU, and the hospital length of stay. On multivariate logistic regression analysis, the factors predicting survival were the admission Acute Physiology and Chronic Health Evaluation II score and baseline driving pressure after adjusting for PaO2:FIO2 ratio, gender, and the etiology of acute respiratory distress syndrome. Conclusions: Tuberculosis is an uncommon cause of acute respiratory distress syndrome even in high tuberculosis prevalence countries. Acute respiratory distress syndrome due to tuberculosis behaves like acute respiratory distress syndrome due to other causes and does not affect the ICU survival.

Outcome of Critically Ill Subjects With Tuberculosis: Systematic Review and Meta-Analysis

BACKGROUND: The outcomes of patients with tuberculosis admitted to an ICU remain undetermined. Herein, we reviewed the literature to describe the mortality of subjects with tuberculosis who are critically ill, and explore the effect of glucocorticoids on survival. METHODS: A systematic review of medical literature databases was performed for studies that describe the outcome of subjects with tuberculosis who required ICU admission. We calculated the proportion of hospitalized subjects with tuberculosis who required ICU admission. Pooled estimates of ICU and hospital mortality, and tuberculosis-related ARDS were calculated. We also studied the effect of systemic glucocorticoids on survival of subjects with tuberculosis who were critically ill. RESULTS: A total of 35 studies (N = 1,815) were included. The pooled proportion of hospitalized subjects with tuberculosis who required ICU admission was 3.4% (95% CI 1.6–5.7%). The pooled ICU and hospital mortality was 48% (95% CI 41–55%) and 54% (95% CI 46–62%), respectively. Tuberculosis-related ARDS was associated with higher odds (odds ratio 3.88, 95% CI 1.73–8.72) of death. The use of glucocorticoids was not related to an improvement in survival (odds ratio 0.65, 95% CI 0.27–1.57). CONCLUSIONS: Tuberculosis is a rare cause of ICU admission but is associated with high mortality. Tuberculosis-related ARDS is also associated with lower survival. The role of glucocorticoids in patients with tuberculosis who are critically ill remains unclear and needs further evaluation.

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in HIV-infected patients with undiagnosed intrathoracic lymphadenopathy

Background: Intrathoracic lymphadenopathy is a common problem in people living with human immunodeficiency virus (PLHIV). There is, however, limited literature on the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in these patients. Herein, we describe our experience with EBUS-TBNA in PLHIV. Materials and Methods: This is a retrospective study of all PLHIV who underwent EBUS-TBNA for the evaluation of intrathoracic lymphadenopathy. We also perform a systematic review of the English literature for studies reporting the yield of EBUS-TBNA in PLHIV. Results: During the study, 1733 EBUS procedures were performed. Among them, 22 (1.3%) were performed in PLHIV. The median age of the individuals (18.2% women) was 46 years. The median CD4 count was 144 cells/mm3. The common lymph node stations involved were station 7, 4R, and 11 L. On endosonographic examination, heterogeneous appearance and coagulation necrosis sign were observed in 14 (63.6%) and 11 (50%) individuals, respectively. EBUS-TBNA was diagnostic in 17 (77.3%) individuals, with tuberculosis being the most common diagnosis (68.2%). There were no major complications related to the procedure. Our systematic review yielded two studies describing the use of EBUS-TBNA in PLHIV. The mean diagnostic yield of EBUS-TBNA was 71% (95% confidence interval: 56–84). Conclusions: EBUS-TBNA is a safe and useful procedure in the evaluation of intrathoracic lymphadenopathy in PLHIV.

Allergic bronchopulmonary aspergillosis presenting as nephrotic syndrome due to secondary amyloidosis: Case report and systematic review of the literature

Allergic bronchopulmonary aspergillosis (ABPA) is a complex inflammatory lung disorder complicating bronchial asthma and cystic fibrosis. Although the condition responds to treatment with glucocorticoids and antifungal drugs, lack of timely recognition, and inadequate treatment of ABPA can lead to progressive lung damage. Uncommonly, long standing inflammation and bronchiectasis can also lead to the development of secondary amyloidosis. Herein, we report a case of ABPA, which presented as nephrotic syndrome and progressed rapidly to end-stage renal disease.