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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 and the National College of Chest Physicians (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 analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definition, epidemiology and disease burden, (b) disease assessment and diagnosis, (c) pharmacologic management of stable COPD, (d) management of acute exacerbations; and (e) non-pharmacologic and preventive measures.

The scope and spectrum of medical research, including that in clinical sciences has tremendously expanded. It now extends from simple clinical observations to gathering of epidemiological data to the study of molecular mechanisms of diseases to evaluation of effects of therapeutic interventions. It is more meaningful to engage in multi-disciplinary and collaborative arrangements for the better achievements in health research. Translational approach involves the direct application of results of laboratory experiments to clinical use for benefit of patients. Besides clinical and experimental research, it is equally important to strengthen operational research for efficient implementation of health programmes and policies in the hospitals as well as in the community. There are several difficulties and constraints related to ethical principles, patient's safety, confidentiality and costs. It is critically important to adhere to ethical principles and guidelines to maintain the moral and social perspectives. It is equally important to follow the scientific research methodology for the maximum gains from research experiments and projects. Interpretation of results of clinical experiments are hardly ever unequivocal, hence, there is a need for repetitive studies, systematic reviews and meta-analyses to reach definitive conclusions. It is important for busy physicians to adopt a scientific temper of logic and engage themselves in searching for answers to different research questions. It is always gainful to spare some time and resources for research out of a busy clinical practice. It is also worthwhile to go through a formal training programme in research methodology to improve capacity and competence to conduct meaningful research.

Background and Aims: Medical thoracoscopy, also called pleuroscopy, has received renewed interest in the recent past for diagnostic as well as therapeutic uses. In this study, we describe our experience with thoracoscopy for undiagnosed pleural effusions., Methods: In a retrospective analysis of thoracoscopic procedures we performed between January 2007 and December 2008, yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleural effusions with adenosine deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy on three occasions was evaluated. Complications of thoracoscopy were also analysed., Results: Overall diagnostic yield of thoracoscopic pleural biopsy was 74.3% in patients with undiagnosed pleural effusions. Pleural malignancy was diagnosed in 48.6% of patients. There was only one case of mesothelioma and the rest were due to pleural metastasis. Lung cancer and breast cancer were the most common sites of primary malignancy. Tuberculosis was diagnosed with pleural biopsy in 22.8% of patients. We had low complication rate after thoracoscopy. Only two cases of empyema were observed., Conclusion: Medical thoracoscopy is a safe procedure and has good diagnostic yield in patients with undiagnosed pleural effusions.

Objective: To study the clinical profile and diagnostic methods in patients with symptomatic pulmonary embolism (PE)., Methods: Prospective assessment of clinical features, radiology and outcome of patients presenting with symptomatic PE over an 18-month period., Results: During study period, 24 patients with a mean age of 39 +/- 12.1 years were diagnosed to have symptomatic pulmonary embolism. Dyspnoea (91.7%) and cough (58.3%) were the predominant complaints. Spiral computed tomographic pulmonary angiography (CTPA) was performed in 21 (87.5%) patients and perfusion scans in 14 (58.4%) patients. Echocardiography performed in all patients revealed evidence of pulmonary artery hypertension and right ventricular dyskinesia in 20 (83.3%) and 15 (62.5%) patients, respectively. Thrombolysis with streptokinase was performed in 14 (58.3%) patients. All patients received low molecular weight heparin followed by warfarin. Of the 24 patients, 20 (83.3%) were discharged and are under regular follow-up; four patients died., Conclusions: Pulmonary embolism is a common problem and can be easily diagnosed provided it is clinically suspected. Early diagnosis and aggressive management is the key to successful outcome.

Background: There is limited information on field epidemiology of bronchial asthma in Indian adults., Objectives: To estimate prevalence of bronchial asthma in different regions of India and to define risk factors influencing disease prevalence., Methods: A field study was conducted at Chandigarh, Delhi, Kanpur and Bangalore through a two stage stratified (urban/ rural) sampling and uniform methodology using a previously validated questionnaire. Asthma was diagnosed if the respondent answered affirmatively both to (a) whistling sound from chest, or chest tightness, or breathlessness in morning, and (b) having suffered from asthma, or having an attack of asthma in the past 12 months, or using bronchodilators. Besides demographic data, information on smoking habits, domestic cooking fuel used, atopic symptoms, and family history suggestive of asthma was also collected. Univariate and multivariate logistic regression modelling was performed to calculate odds ratio of various potential risk factors., Results: Data from 73605 respondents (37682 men, 35923 women) were analysed. One or more respiratory symptoms were present in 4.3-10.5% subjects. Asthma was diagnosed in 2.28%, 1.69%, 2.05 and 3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore, with overall prevalence of 2.38%. Female sex, advancing age, usual residence in urban area, lower socio-economic status, history suggestive of atopy, history of asthma in a first degree relative, and all forms of tobacco smoking were associated with significantly higher odds of having asthma., Conclusion: Prevalence estimates of asthma in adults in this study, although lower than several previously reported figures, point to a high overall national burden of disease.

Introduction: Population prevalence of chronic obstructive pulmonary disease (COPD) and its relationship with tobacco smoking, environmental tobacco smoke (ETS) exposure and other variables were studied in adult subjects of 35 years and above at four different centres in India. Question-items for the diagnosis of COPD were included in the questionnaire used for the field study on asthma epidemiology., Methods: Field surveys were conducted in both the urban and the rural populations at Bangalore, Chandigarh, Delhi and Kanpur with the help of a structured and validated questionnaire for diagnosis of asthma and COPD. Separate sets of questions were used for the diagnoses of the two diseases. A two-stage stratified sample design was employed where a village or an urban locality formed the first stage unit and a household formed the second stage unit. A uniform methodology was used at all the four centres and the analyses were done at the central coordinating centre--Chandigarh. Chronic obstructive pulmonary disease, defined by chronic bronchitis (CB) criteria, was diagnosed from the presence of cough and expectoration on most of the days for at least three months in a year for two consecutive years or more., Results: Chronic obstructive pulmonary disease was diagnosed in 4.1% of 35295 subjects, with a male to female ratio of 1.56:1 and a smoker to nonsmoker ratio of 2.65: 1. Prevalence among bidi and cigarette smokers was 8.2% and 5.9%, respectively. Odds ratio (OR) for COPD was higher for men, elderly individuals, lower socio-economic status and urban (or mixed) residence. Environmental tobacco smoke exposure among nonsmokers had an OR of 1.4(95% CI 1.21-1.61). Combined exposure to both ETS and solid fuel combustion had higher OR than for ETS exposure alone., Conclusions: Population prevalence of COPD is very high in India with some centre to centre differences. Smoking of both bidis and cigarettes, and ETS exposure among nonsmokers, were two important risk factors at all centres. It is important to employ uniform methodology for assessment of national burden and disease-surveillance programme.

Background: Population prevalence of tobacco smoking especially with reference to detailed habits such as the amount smoked, the smoking forms, quit-rates and relationship with demographic variables were studied at four different centres in India along with the study on epidemiology of asthma and chronic obstructive pulmonary disease., Methods: The study population included adults of over 15 years of age selected with two-stage stratified random sample design. A specifically designed questionnaire was used for the study., Results: There were 11496 (15.6%) ever smokers in the study sample of 73605 subjects. Among 37682 males, 10756 (28.5%) were ever smokers and among 35923 females, 740 (2.1%) were ever smokers. Bidi was the commonest form of smoking, more so in the rural areas. The mean number of cigarettes/bidis smoked per day was 14 (+/- 11.5) and the mean age of starting smoking was 20.5 (+/- 20.0) years. Increasing age, low socio-economic status and rural residence were important factors associated with smoking. Vigorous anti-tobacco measures under the tobacco control programmes yielded only a quit-rate of 10 percent. Nearly 14% of ever smokers had some respiratory symptoms., Conclusions: A substantial proportion of population in India has current or past smoking habit with higher prevalence among males than females. The quit-rates have been low in spite of the various anti-tobacco measures. There is a significant respiratory morbidity associated with smoking.

Background: Exposure to environmental tobacco smoke (ETS) is a risk factor for childhood asthma. Its association with asthma in adults is less clear., Methods: In a multicentric population study on asthma prevalence in adults, specific enquiries were made into childhood and adulthood exposure to household ETS, and its relationship with asthma diagnosis were analysed., Results: From a total of 73605 respondents, 62109 were studied after excluding current or past smokers. Overall observed prevalence of asthma was 2.0% (men 1.5%,women 2.5%, p < 0.001). Of all asthma patients, history of ETS exposure was available in 48.6 percent. Prevalence of asthma in the ETS exposed subjects was higher compared to non-exposed individuals (2.2% vs 1.9%, p < 0.05). Multiple logistic regression analysis showed a higher risk of having asthma in persons who were exposed to ETS compared to those not exposed (odds ratio [OR] 1.22, 95% CI 1.08-1.38) after adjusting for age, gender, usual residence, exposure to biomass fuels and atopy. Stratification of ETS exposure revealed that exposure during childhood and both during childhood and adulthood were significantly associated with asthma prevalence. Exposure only in adulthood was not a significant risk factor (OR 1.13, 95% CI 0.95-1.33). Persons reporting combined environmental tobacco smoke exposure from parents during childhood and spouse during adulthood had highest risk of having asthma (OR 1.69, 95% CI 1.38-2.07). Environmental tobacco smoke exposure was also significantly associated with prevalence of respiratory symptoms such as wheezing, cough and breathlessness., Conclusions: Environmental tobacco smoke exposure during childhood is an important risk factor for asthma and respiratory symptoms in non-smoking adults.

Objectives: To determine the prevalence of pulmonary hypertension in patients with idiopathic pulmonary fibrosis (IPF) by noninvasive methods., Patients and Methods: Twenty seven patients with IPF attending the Chest Clinic over a period of one-and-a-half-years underwent echocardiography for evidence of pulmonary hypertension, which was defined as pulmonary artery systolic pressure > or = 40 mmHg by Doppler echocardiography, or pulmonary acceleration time < or = 100 milliseconds or two-dimensional echocardiographic findings of right ventricular hypertrophy or overload., Results: Two patients with clinical evidence of pulmonary hypertension were excluded from analysis. Their mean age (n = 25) was 53.8 years. The mean duration of symptoms before presentation was 2.1 years. Pulmonary hypertension was diagnosed by echocardiography in nine of the 25 patients (36%). There was a statistically significant difference between the duration of illness, arterial oxygen tension (PaO2) levels and forced vital capacity in patients with pulmonary hypertension than in those without pulmonary hypertension. Logistic regression analysis showed a significant association between the duration of illness, decreasing forced vital capacity and hypoxemia with the development of pulmonary hypertension., Conclusions: Echocardiography detects pulmonary hypertension in clinically asymptomatic individuals, and should be used routinely for the diagnosis of pulmonary hypertension in patients with IPF.

Background: Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of pulmonary diseases, but in many instances the procedure has to be repeated because of an inconclusive initial FOB or for reassessment., Methods: A retrospective analysis of all the fiberoptic bronchoscopic procedures done between September 2000 and February 2003 was performed and details of patients undergoing repeat FOB abstracted., Results: Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated, yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in 112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The major indications for repeating FOB included obtaining specimens for pathological examination, pre and postoperative evaluation of airways, localization of site of bleeding in patients with hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results, either in form of positive histology or localisation of source of hemoptysis., Conclusions: The frequency of repeat bronchoscopy was low. Commonest indication for a repeat procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield positive results even when the initial FOB is nondiagnostic.

Background: Tobacco use, which is the cause of several respiratory diseases, generally starts in the teens. Global Youth Tobacco Survey (GYTS) is an international initiative to investigate the tobacco use in school going youth of 13 to 15 years of age. This report describes the GYTS findings in the North Indian region., Methods: A two-stage cluster sample was used with selection of schools on probability proportional to enrollment size followed by systematic equal probability sampling with a random start of classes from each school. The 85-item questionnaire included 'core GYTS' and other additional questions. Data analysis was performed using EpiInfo 3.2 software and the results accounted for the complex sampling design and weighting factors in the data set., Results: The sample consisted of 9319 students out of the total eligible population of 30488 from 100 schools. The prevalence of ever-use of tobacco varied between 2.9 to 8.5% in boys and 1.5 to 9.8% in girls. The prevalence was highest in Chandigarh and lowest in Punjab. Between 16 to 46% of students were exposed to the habit of tobacco among parents or friends. There were 10 to 34% students who were passively exposed to environmental tobacco smoke., Conclusion: Tobacco use is present in up to 10 percent of school going youth in the region. A majority of them had desired to quit. Tobacco control and cessation programmes therefore, remain important health issues.

Objective: To develop a simple software for management of fibreoptic bronchoscopy records., Methods: After identification of the specific needs at our hospital, a software was developed. A graphical interface with structured data entry related to patient information and diagnosis, bronchoscopic findings and specimens obtained, and their reports were envisaged. After initial construction, the software was tested over a four-week period. The software was put to routine use after necessary corrections, and validated over the next few months through actual data entry., Results: The software has various modules for input and modification of data, as well as for generation of reports, and can work both on stand-alone personal computers and on networks. With little practice, residents soon became adept at entering details correctly and quickly. The slightly increased time of data entry into the computer was more than made up by uniform and complete report generation. The database component was evaluated by analyzing 1000 consecutive records entered over a 14-month period, and no discrepancies were observed., Conclusion: A user-friendly software providing uniform and complete data entry regarding fibreoptic bronchoscopic procedures was developed.

Background: Combination chemotherapy has been demonstrated as one of the best active regimens in patients with non-small cell lung cancer (NSCLC)., Methods: A total of 206 patients with advanced unresectable NSCLC stage III B or stage IV were enrolled to receive combination chemotherapy with mitomycin, ifosfamide and cisplatin. About a third of them (n=63) did not continue therapy after the first course either because of toxicity, lack of affordability, or death. The remaining 143 patients (121 males) received two or more cycles of chemotherapy., Results: Nearly half of all followed-up patients showed a partial or complete radiological response. Overall performance status (Karnofsky scale) worsened in 28 (19.6%) and improved in 44 (30.8%). While 50 patients (35%) gained weight, 65 (45.5%) lost weight during follow-up. Overall median survival was 20 weeks [95% confidence interval (CI), 16 to 24 weeks]. However, overall survival improved progressively with the number of chemotherapy cycles administered. Median survival in patients receiving at least three, four and five chemotherapy cycles was 23 (95% CI, 19-27); 27 (95% CI, 24-30) and 35 (95% CI, 28-42) weeks respectively. Survival at the end of three, six, nine and 12 months was 64.3%, 29.4%, 14.7% and 9.8%) respectively. Survival had no association with age of the patient, but was significantly correlated with baseline performance status (Pearson's correlation coefficient 0.29 p<0.01). The cost of each course of chemotherapy was a little over 100 US dollars. The side effects were minimal and acceptable, and the regimen was tolerated well by all the patients., Conclusion: Ifosfamide regimen containing mitomycin and cisplatin is a chemotherapeutic combination for treating patients with advanced NSCLC.

Objective: To study the clinical profile of patients with idiopathic pulmonary fibrosis (IPF) and methods used for diagnosis., Methods: Prospective analysis of symptoms, signs, radiology and lung biopsy of patients freshly diagnosed to have IPF over a 16-month period., Results: During the study period, 76 patients (35 men) with a mean age of 50.6 +/- 11.9 years were diagnosed to have IPE Breathlessness (98.6%) and dry cough (92.1%) were the most common presenting symptoms. Transbronchial lung biopsy (TBLB) was performed in 38 (50%) patients. Histopathological examination revealed features consistent with IPF in 35 (92.1%) patients; two of the remaining three patients underwent open lung biopsy. Other patients were diagnosed based on clinical features and high resolution chest tomography (HRCT) findings. HRCT was performed in 69 (90.8%) patients; all had features suggestive of diffuse interstitial fibrosis., Conclusion: IPF is diagnosed more commonly now than in the past. Indian patients may be developing the disease a decade earlier than their counterparts in the West. TBLB and HRCT are useful in establishing diagnosis. IPF should be considered a distinct clinical entity rather than a diagnosis of exclusion.

Background: Bronchoscopic examination has been advocated as an essential part of evaluation of patients with newly diagnosed esophageal malignancy. The present study describes the role of routine preoperative fibreoptic bronchoscopy in staging disease and assessing resectibility in patients with malignancy involving the middle third of esophagus., Methods: Preoperative fibreoptic bronchoscopy was performed in 125 patients with carcinoma of the middle third of esophagus. None of the patients had clinical or chest radiographic evidence of extension of disease outside the esophagus., Results: Abnormalities were detected in 33 patients (25.6%), the commonest being external compression over the posterior wall of trachea in 17 (13.6%). Other abnormalities noted were left vocal cord paresis in seven (5.6%); compression over one or both major bronchi in seven (5.6%) and over the left lower lobe bronchus in one (0.8%); infiltration of the left main bronchus in two (1.6%); and growth in trachea in four (3.2%), in left main bronchus in two (1.6%) and over cricoarytenoid area in one (0.8%) patient., Conclusions: Tracheobronchial involvement, even in the absence of clinical or radiological features, is not uncommon in esophageal cancer. Preoperative bronchoscopy is useful to assess the extent of disease and resectibility in these patients.

Objective: To study the presence and pattern of haematological abnormalities in patients with sarcoidosis in India., Methods: Haematological investigations including complete blood cell counts, ESR and peripheral smear examination were carried out in 30 consecutive freshly diagnosed cases of sarcoidosis and compared with equal number of age and sex matched healthy controls. Coagulation parameters such as prothrombin time (PT), prothrombin index (PTI), partial thromboplastin time (PTTK) and fibrinogen levels were also studied., Results: There were 15 men (mean age 40.4 +/- 10.15 years) and equal number of women (mean age 38.6 +/- 12.14 years) in the study group. Haematological abnormalities were present in 11 (36.66%) of the patients. Four cases (13.33%, all females) were found to have anaemia and in three of them no other cause for this was evident. Lymphopenia (lymphocyte count <1500/cu mm) was present in eight (26.66%) patients and three (10%) controls (P<0.05). Only one patient (3.3%) had leucopenia. Number of subjects with raised ESR and the mean ESR was higher in the study group as compared to the controls. No coagulation abnormalities were encountered., Conclusions: Different haematological manifestations in total are common in Indian patients, leucopenia is relatively rare while anaemia, lymphopenia and raised ESR are common

Three hundred seventy three previously diagnosed patients with lung cancer, attending the Lung Cancer Clinic at this institute were studied. Chest radiographs were interpreted in all cases. Radiography was compared in different cell types. Squamous cell carcinoma 158 (42.4%), followed by small cell lung cancer 122 (32.7%), was the commonest histological subtype. Upper zone was involved in maximum number of cases 158 (42%), followed by mid zone 122 (32.7%), lower zone 60 (16%) and the entire lung 33(8.8%). Adenocarcinoma presented as a peripheral mass in 37 (61%) cases and in 23 (38.3%) as a central lesion. Presentation as a central mass (114, 72.2% cases) was more common among squamous cell carcinoma than as a peripheral lesion (44, 27.8% cases). Similarly, small cell cancer also presented more commonly as a central lesion (102, 83.6% cases) than as a peripheral lesion (20, 16.4% cases). Isolated pleural effusion was present in 3.8% in squamous cell lung cancer, 22% in adenocarcinoma and only 4% in small cell lung cancer.

An attempt has been made to estimate the gross burden of chronic obstructive pulmonary disease (COPD) and its smoking association by reviewing the population studies available from India. Of the 14 studies which were reviewed, there were 11 conducted in general populations. The median values of different prevalence rates (i.e. 5 percent in male and 2.7 percent in female population) were accepted as the most appropriate figures to calculate the overall estimates. The overall M:F ratio was 1.6:1, i.e. 61.6 percent males. The estimated total number of adult patients aged 30 years and above in 1996 were 8.15 million males and 4.21 million females. The smoker:non-smoker ratio in males was assessed at 82.3 percent with an estimated burden of 6.7 millions. When the prevalence rates of COPD and its smoking associations were assessed in three different time periods (before 1970; between 1971-1990; after 1990), the median rates of 1971-1990, when the maximum number of studies were conducted, were nearly the same as the overall rates. However, the total burden as well as the smoking associated COPD, increased with time due to an increase in the eligible base population. In conclusion, these figures can be used to estimate the burden of COPD and its smoking association in India for different statistical analyses.

Pulmonary fibrosis is a common complication in progressive systemic sclerosis (PSS). Physical examination and/or routine pulmonary function tests can, however, detect only relatively advanced disease. We assessed the utility of static lung pressure-volume analysis in detecting lung involvement in patients of PSS without obvious clinical, radiological or spirographic evidence of pulmonary disease. Static lung volumes were determined and expiratory lung pressure-volume measurements were obtained in 10 patients with PSS, using a computerized whole body plethysmograph. Static pressure-volume data was also subjected to monoexponential analysis. All patients had normal total lung capacity. Three patients had reduced static compliance, of whom one also had reduced value for the shape constant K (calculated from exponential analysis of pressure-volume data). Examination of pressure volume curve showed a pattern consistent with interstitial fibrosis in these patients. We conclude that detailed study of lung mechanics can help identify early pulmonary involvement in patients with PSS.

There has been an increasing recognition of respiratory mycoses in this country in the recent past. Candidiasis, aspergillosis and cryptococcosis have been reported from different centres. Occasional cases of histoplasmosis and sporotrichosis have also been reported. Infections with Pneumocystis carinii, which is now classified as a fungus, are being frequently diagnosed, especially in the immuno-compromised patients such as those on prolonged immunosuppressive therapy or with HIV infection. Although the clinical picture of respiratory mycoses resembles that of any other infection, the presentation in several cases is atypical and the diagnosis is delayed. In a review of our patients of respiratory fungal infections seen in the last few years, we found several interesting examples. We report here the general clinical spectrum of respiratory mycoses and some interesting cases seen at our Centre.

We describe here two patients with tracheobronchial involvement by amyloidosis. One of them had presented with discrete tracheobronchial mass lesions simulating bronchogenic carcinoma. The other had intermittent streaky hemoptysis and was found to have diffuse tracheobronchial involvement at bronchoscopy. Both patients are doing well without any definitive therapy.

Background: Measurements of dyspnoea in asthma are difficult. Peak expiratory flow (PEF) and forced expiratory volume in first second (FEV1) are the most widely used objective measures of bronchial obstruction in asthma. Subjective continuous scales like visual analogue scale (VAS) provide a more flexible means of grading dyspnoea as perceived by the patient., Methods: Utility of a VAS in assessing severity of bronchial asthma was evaluated in 195 previously diagnosed adult patients with bronchial asthma. Patients were asked to mark their severity as perceived by them on a continuous vertical VAS of 100 mm anchored at bottom with description no breathlessness' and at top by 'greatest breathlessness'. The distance measured from bottom in mm was taken as VAS score. This was correlated with FEV1 and PEF recorded immediately after the scale was marked., Results: The mean VAS score was 31.13 (+/- 28.32) mm and had a good negative correlation with FEV1 (r = 0.5255, p < 0.01) and PEF (r = 0.4609, p < 0.01). Patients were also classified into four groups of mild, moderate, severe and acute asthma, and correlation analyzed in each group separately. The correlation was more significant in subgroups of moderate and severe asthma. Educational status of subjects had no impact on this correlation., Conclusion: VAS is a reasonable tool for measurement and monitoring of severity of asthma in individual patients, and may be used when more objective tests are not available.

Diurnal variability in peak expiratory flow (PEF) was studied for three days in 152 healthy volunteers aged 20-40 years, and expressed as amplitude percent mean (A%M) and standard deviation percent mean (SD%M). The commonest pattern (74.6%) observed was that of a nadir at waking in morning, a progressive rise upto late afternoon and a plateau or a small decrease at bedtime. Mean diurnal variation in PEF on the third day was 7.23 +/- 3.48 (A%M) and 2.98 +/- 1.31 (SD%M). Both the diurnal variation and the calculated upper limits of normality were found to be lower than those reported previously for Western subjects. This knowledge of diurnal variation is important for any meaningful interpretation of PEF recordings used to monitor patients with asthma.

We report a case of a young female patient with typhoid fever whose clinical course was complicated by hypotension, thrombocytopenia, encephalopathy and acute respiratory distress syndrome (ARDS). She recovered with prompt mechanical ventilatory support. ARDS in typhoid fever has generally proved to be fatal in reported cases.

Effect of chronic environmental tobacco smoke (ETS) exposure on bronchial responsiveness (BR) was assessed by the measurement of BR in stable, nonsmoker asthmatic women and comparison of the PD20 in the exposed and non exposed groups was also studied. Nonspecific bronchoprovocation test was performed by histamine inhalational challenge. Of fifty patients included in the study, 23 (46%) had history of ETS exposure of 1.22 (+/- 0.61) hours per day for an average of 13.07 (+/- 6.1) years. The PD20 was significantly lower in the ETS exposed group (p < 0.05). When the subjects were compared, based on their cumulative exposure expressed by an exposure index (El = duration of exposure in years multiplied by average number of hours per day), there was a statistically significant difference in PD20 of those with El of less than those with El of more than 15. It is concluded that BR is greater, and reflects the higher morbidity in the ETS exposed patients of asthma.

Tuberculosis is a common cause of pleural effusion in India. Diagnosis can be made in a majority of patients from the clinical features, pleural fluid examination (including cytology, biochemistry and bacteriology), and pleural biopsy. Adenosine deaminase estimation in pleural fluid is occasionally useful. Newer diagnostic techniques include lysozyme or interferon gamma estimation, immunodiagnostic methods and polymerase chain reaction. Although promising, they still need to be studied further before their routine use can be recommended.

A young laborer was accidentally exposed to toxic nitrogen dioxide fumes following an accidental explosion at work place. He developed acute respiratory distress within few hours of exposure and manifested with severe hypoxemia and permeability edema. Assistance with mechanical ventilation and corticosteroid therapy could be instituted only after 24 hours of exposure. He had shown remarkable recovery and could be weaned off after seven days. At three weeks after discharge, his lung function tests were normal.

Fifty four patients of idiopathic pulmonary fibrosis were evaluated retrospectively to see the effect of prednisolone therapy on the course of the disease. The diagnosis was established based on clinical history, physical findings, radiology, HRCT, spirometry and transbronchial biopsy whenever possible. Each patient received prednisolone 1 mg/kg/day for 6 weeks which was then tapered gradually till a maintenance dose was achieved. Six patients (11.1%) died within 3 months (3 within 1 month) of presentation because of rapid progression of the disease and inspite of addition of intravenous methyl prednisolone. Improvement in symptomatology, particularly cough and dyspnoea, were quite variable. Twenty six (48.1%) reported subjective improvement by 20-80% of the initial symptoms. However, in most cases this improvement was for the initial 3-6 months of therapy. Subsequently either they deteriorated or remained stable. There was no clinical improvement in the remaining 20 patients (improvement in symptoms by 0 to less than 20%). There was no radiological improvement in any case. FVC improved at 3 months only after treatment compared to the baseline values (p < 0.01). However, subsequently there was no significant improvement in the lung function. Of the 37 cases whose initial FVC value could be obtained, 8 patients (21.6%) showed an improvement by more than 20% of their baseline values during their follow up period. Of these, 4 had the improvement by 3 months; 3 by 6 months; and one showed improvement at 1 year and 6 months. Five patients (13.5%) had a decrease in FVC by 10% or more during their follow up. One patient developed sputum positive pulmonary tuberculosis nine months after steroid therapy.

The use of endotracheal intubation for respiratory support of critically ill patients has become a standard life saving form of therapy. Most complications of intubation become apparent only after extubation which may manifest in the early or late post extubation period. This study was undertaken to demonstrate the occurrence and extent of laryngotracheal injuries in intubated patients by performing flexible fibreoptic bronchoscopy at varying intervals following extubation. It was found that initial laryngoscopy findings were more pronounced in patients intubated for upto twelve days. Furthermore, it was also observed that the initial laryngeal pathology seen on fibreoptic laryngoscopy was not an accurate predictor for the development of adverse post extubation sequelae. Maxillary sinusitis developed significantly in patients intubated nasally. Routine flexible fibreoptic examination of the larynx following extubation is recommended for early detection of granulomas, synechia of vocal cords and vocal cord immobility to prevent troublesome sequelae.

Forty-six patients with peripheral lung lesions underwent ultrasound-guided percutaneous needle aspiration biopsy. Aspirates were sent for cytological and/or microbiological examination. Confirmative diagnosis was obtained in 40 patients (86.9%). Twenty-eight patients had positive cytology for malignancy and 12 patients with benign lesions had diagnosis made by cytologic and microbiologic examination. None of the lesions could be diagnosed by sputum cytology and fibreoptic bronchoscopy with biopsy or brushings. No complication was observed in any patient. We conclude that ultrasound guided aspiration biopsy is a useful and safe method for the diagnosis of peripheral pulmonary masses. The diagnostic yield far exceeds that which can be obtained by sputum cytology and fibreoptic bronchoscopy with biopsy.

A 40-year-old male patient with chronic steroid dependent asthma developed pulmonary tuberculosis. After administration of antituberculosis therapy with rifampicin, isoniazid and pyrazinamide his asthma worsened. Omission of rifampicin from the drug regimen successfully controlled bronchospasm.

A combination chemotherapy consisting of VP-16, vincristine, cyclophosphamide and CCNU was used to treat 24 patients of small cell lung cancer (extensive stage disease - 15 and limited stage - 9). In addition, radiotherapy of 1000 to 4000 cGys was given to primary disease in chest in 16 patients. The overall response rate was 95.8% with complete response (CR) in 9 (37.5%) and partial (PR) in 14 (58.3%) cases. The overall median survival was 24 weeks. In patients with CR, it was 39 weeks and in those with PR this was 22.5 weeks. The lone non-responder survived for only 8 weeks. The drugs were well tolerated.

Clinical profile of 35 patients with allergic bronchopulmonary aspergillosis (ABPA) was analysed. The disease was found to be more frequent among females. Constitutional symptoms, expectoration, increased breathless and poor control of asthma were the main presenting features. Skin reactivity against aspergillin and Candida was positive in 30 and 2 cases, respectively. Precipitating antibodies against Aspergillus species was positive in 28 cases, and against Candida albicans in 2 cases. Sputum grew either Aspergillus or C. albicans or both in 19 patients. Absolute eosinophilia was observed only in one third of cases. Chest skiagram revealed characteristic central/proximal bronchiectasis and/or fleeting shadows in all cases. No specific pattern was observed on spirometry. There was no correlation between the duration of bronchial asthma, sputum culture and serology results. Most patients responded well to steroids. One striking feature of the study was that one third of the cases were misdiagnosed as pulmonary tuberculosis and were treated with antitubercular drugs for varying periods of time. A high index of clinical suspicion with appropriate laboratory tests are required to identify these cases.

A retrospective analysis was done of computerized tomographic (CT) scans of 29 patients with image guided histologically proven mediastinal tubercular lymphadenitis. Amongst these 19 patients were males while 10 were females in the age range of 2-65 years. Plain radiographs of all the patients revealed mediastinal lymphadenopathy. There was a high incidence of involvement of right paratracheal and tracheobronchial lymph nodes. The lymph nodes larger than 2 cm showed central low density area with peripheral enhancing walls. However, nodes less than 2 cm in size were mostly homogenous.

During the last 4 years, fifty-seven patients of acute severe asthma (ASA) were admitted to intensive care unit (ICU). Twenty-three patients required mechanical ventilation (MV) on 25 occasions. Indications to intubate were persistent hypoxia (PaO2 < or = 55 mm Hg) or hypercapnia with respiratory acidosis (64%), abnormal mentation (24%) and respiratory arrest (12%). All the patients were monitored for clinical features, arterial blood gases (ABG) and peak airway pressure (PAP). During MV, there was one case of pneumothorax (4%), seven (28%) cases of transient hypertension and one (4%) patient died. Mean duration of MV was 3 days and the outcome was favourable. Therefore, resorting to aggressive treatment early in the course of disease proves life saving in acute severe asthma.

Haemoptysis is a clinical problem which occurs in association with a variety of disorders. We report a patient who presented with the triad of haemoptysis, anaemia and diffuse alveolar consolidation suggesting diffuse pulmonary haemorrhage (DPH).

A patient with benign posterior mediastinal teratoma which is a rare site for teratomas is reported. Chest skiagram and CT of the thorax established the diagnosis. Complete removal of the mass was not possible on surgery as it was adherent to the pericardium and the esophagus. The patient remained asymptomatic one year after the surgery. There was no evidence of recurrence of the tumor.

A patient of chronic obstructive pulmonary disease (COPD) with cor-pulmonale and chronic respiratory failure, who was given intermittent positive pressure ventilation at home, is reported. The patient did remarkably well on home mechanical ventilatory support. We believe this to be the first case report of domiciliary mechanical ventilation in a patient of COPD from India.

A case with diagnosis of non-Hodgkin's lymphoma and superior vena cava obstruction on chemotherapy, presented with respiratory distress and massive pleural effusion of right hemithorax. On removal of 3.5 litres of fluid, he developed pulmonary edema of the same side and hypotension.

Thirty-four patients with non small cell lung cancer were treated with a combination of vinblastin and mitomycin-C. Major radiological response was observed in 61.5% of cases. Median survival of the treated patients was 6 months and it was 7 months for those showing a major response. Fourteen of the 21 responders survived for 6 months or more, and 4 survived for more than a year. Leucopenia was a common side effect, and it did not produce any major infective complication. We did not find any advantage of this regimen over other less expensive drugs used in our earlier trials.

A young man with spontaneous pneumothorax who suffered from fourth recurrence, is being reported. He was treated by surgical pleural abrasion.