Search

Background and Objectives: Chronic obstructive pulmonary disease (COPD) is a common airway disease that is frequently associated with comorbidities. In this study, we assessed the co-existence of obstructive sleep apnea (OSA) among patients with stable COPD. Methodology: This cross-sectional study included patients with stable COPD who were screened with Epworth's Sleepiness Scale (ESS). Those with ESS score of >10 were subjected to in-lab polysomnography (PSG). PSG was manually analyzed and reported. Patients with apnea–hypopnea index of >5/h were diagnosed as OSA. Results: This study included 301 patients (78.1% male, 76.4% smokers, age 59.6 ± 10 years) with stable COPD. ESS score of >10 was observed in 47 (15.6%) patients. Among patients with ESS score of >10, OSA was observed in 34 (72.3%) patients. The overall prevalence of OSA among patients with COPD was 10.9%. Patients with co-existing OSA were older and had thicker neck and higher body mass index (BMI) as compared to COPD alone. In addition, patients with associated OSA had worse health-related quality of life (QOL) as shown by higher St. George's Respiratory Questionnaire score (42.42 ± 7.22 vs. 25.22 ± 8.66; P < 0.001). Conclusions: Co-existing OSA is common among patients with COPD and has a significant adverse effect on the QOL. Among COPD patients, older age, thick neck, and high BMI may predict co-existing OSA and require PSG for the confirmation.

Background: EGFR over-expression plays a key role in the development and progression of lung cancer. However, its status as a prognostic biomarker for survival outcomes is unclear. Objectives: To evaluate the prognostic utility of serum EGFR mRNA expression in Non-Small cell lung cancer (NSCLC) for treatment response and survival. Methods: EGFR mRNA levels were determined in serum using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Based on ROC curve, a cut off value of 16.0-fold increase was selected to categorize patients into low EGFR (≤ 16.0) and high EGFR (> 16.0) groups. Results: A total of 350 subjects were included (78.3% males), with mean (± SD) age of 57.1 (± 11.2) years, and including 247 (70.6%) adenocarcinoma (ADC). Majority (73.1%) had metastatic (stage IV) disease. Patients had higher pre-treatment serum EGFR mRNA levels than controls [median fold-increase (min, max), 16.2 (1.9, 66.7). Serum EGFR mRNA levels significantly reduced in those who achieved objective response and disease control. Significantly longer OS and PFS was observed in subjects having baseline EGFR mRNA expression ≤ 16.0 fold- increase compared to those with > 16.0 fold- increase [median (95% CI) OS: 25.0 (14.9, NR) versus 7.7 (6.3, 8.9) months; HR (95% CI) 2.9 (2.3, 4.0), p < 0.001; and PFS: 9.9 (7.1, 11.5) versus 6.0 (4.1, 7.5) months; HR (95% CI) 1.8 (1.3, 2.4), p < 0.001]. Conclusion: Serum EGFR mRNA expression is a useful parameter for predicting treatment response and survival outcomes in NSCLC.

Dysregulation of IFN-α is the basis for pathogenesis of autoimmune as well as infectious diseases. Identifying inflammatory signatures in peripheral blood of patients is an approach for monitoring active infection. Hence, estimation of type I IFNs as an inflammatory biomarker to scrutinize disease status after treatment is useful. Accordingly, an Aptamer Linked Immobilized Sorbent Assay (ALISA) for the detection of IFN-α in serum samples was developed. Sixteen aptamers were screened for their ability to bind IFN-α. Aptamer IFNα-3 exhibited specificity for IFN-α with no cross-reactivity with interferons β and γ and human serum albumin. The disassociation constant (Kd) was determined to be 3.96 ± 0.36 nM, and the limit of detection was ∼2 ng. The characterized IFNα-3 aptamer was used in ALISA to screen tuberculosis (TB) patients' sera. An elevated IFN-α level in sera derived from untreated TB patients (median = 0.31), compared to nontuberculous household contacts (median = 0.13) and healthy volunteers (median = 0.12), and further a decline in IFN-α level among treated patients (median = 0.13) were seen. The ALISA assay facilitates direct estimation of inflammatory protein(s) in circulation unlike mRNA estimation by real time PCR. Designing of aptamers similar to the IFNα-3 aptamer provides a novel approach to assess other inflammatory protein(s) in patients before, during, and after completion of treatment and would denote clinical improvement in successfully treated patients.

Nebulized medications are frequently administered in both acute and chronic conditions-viz., management of acute asthma and COPD exacerbations, home maintenance treatment for chronic respiratory diseases like COPD, bronchiectasis, and cystic fibrosis, etc. However, the viral pandemic of COVID-19 has raised concerns on the use of nebulization. This document is intended to provide guidance to physicians on the role and use of nebulization in the current pandemic, based on current evidence and understanding.

Background: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. Methods: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. Results: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. Conclusion: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

Background: The optimal strategy for the withdrawal of noninvasive ventilation (NIV) remains unknown. This study was planned to compare three different strategies for the withdrawal of NIV among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory failure (HcRF). Materials and Methods: Patients with AECOPD with HcRF who improved on NIV were randomized into three groups – immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C) of NIV. The probability of successful withdrawal was compared among the groups. Results: This study included 90 patients (males – 86.6%) with a mean (±standard deviation [SD]) age of 59.9 ± 8.3 years. The mean (±SD) pH and PaCO2 at admission were 7.23 ± 0.04 and 84.4 ± 12.0 mm Hg, respectively. The duration of NIV received before randomization was 31.6 ± 9.2 h with maximum inspiratory positive airway pressure and expiratory positive airway pressure of 17.6 ± 2.7 cm H2O and 7.4 ± 1.4 cm H2O, respectively. NIV was successfully withdrawn in 23/30 (76.6%) in Group A, 27/30 (90%) in Group B, and 26/30 (86.6%) in Group C (P = 0.31). The total duration of NIV use and length of hospital stay was lower in Group A and B as compared to Group C (P = 0.001). Conclusions: Immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible. Immediate withdrawal did not increase the risk of weaning failure from the NIV.

A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio 200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

Background: Diaphragm thickness measurement by ultrasonography (USG) has been shown to be a good surrogate of diaphragmatic functions. However, data regarding reliability of diaphragm thickness measurement by critical care physicians among patients with sepsis is limited. Aims and Objective: This study was designed to assess the variability and reliability of diaphragm thickness measurement on USG by critical care physician in patients with sepsis. Materials and Methods: Study included patients with sepsis who were admitted between March 2015 and December 2016 in a tertiary care center. Three readings of diaphragm thickness were recorded separately during inspiration and expiration using B-mode of USG. Mean [standard deviation (SD)] of variation and intraclass correlation coefficient (ICC) in the measurement were calculated for assessment of variability and reliability, respectively. Results: Four hundred twenty measurements on 70 patients were included in the study. Mean (SD) variation for 1st, 2nd, and 3rd measurement during expiration were 0.233 (0.027) mm, 0.231 (0.029) mm, and 0.233 (0.029) mm, respectively. During inspiration mean (SD) variation for 1st, 2nd, and 3rd measurement were 0.285 (0.033) mm, 0.283 (0.031) mm, and 0.283 (0.033) mm, respectively. The ICC [95% confidence interval (CI)] among 1 vs. 2, 1 vs. 3, and 2 vs. 3 readings taken during expiration were 0.930 (0.889–0.956), 0.919 (0.873–0.949), and 0.940 (0.905–0.963), respectively. During inspiration, ICC (95% CI) among 1 vs. 2, 1 vs. 3, and 2 vs. 3 readings were 0.949 (0.919–0.968), 0.940 (0.905–0.962), and 0.945 (0.914–0.966), respectively. Overall ICC for three readings of diaphragmatic thickness during expiration and inspiration were 0.930 (0.898–0.954); P < 0.001 and 0.945 (0.919–0.963); P < 0.001, respectively. Conclusion: The measurement of diaphragm thickness using USG by critical care physicians among patients with sepsis is reliable with minimal variability.

Background: Alterations in body composition are common in cancer and may affect outcomes differentially based on geographical and ethnic factors. However, data in lung cancer are sparse and conflicting. Methods: We compared the body composition of Indian lung cancer patients with healthy subjects using a retrospective review of all newly diagnosed patients with nonsmall cell lung cancer. Age- and sex-matched healthy controls were recruited prospectively. Basal metabolic rate (BMR), total body water (TBW), fat mass, and fat-free mass (FFM) were calculated by bioelectric impedance method. Results: A total of 256 patients (83.6% males) and 210 controls (81.4% males) were studied. The mean (standard deviation) age of patients was 54.5 (9.0) years, median smoking index was 598.2 (range, 0–2500), and median Karnofsky performance scale (KPS) was 80 (range, 40–100). Majority (54.7%) had Stage IV disease. All components of body composition, i.e., BMR, TBW, fat mass, and FFM, were significantly lower (P < 0.01) in patients as compared to controls. Body mass index, fat mass, FFM, and TBW were lower in older subjects with poorer KPS. The presence of metastasis or symptom duration did not affect body composition. Conclusion: These results indicate that Indian patients with lung cancer have altered body composition which declines with increasing age and worsening performance status.

Background Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p Results Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.

The management of coronavirus disease-2019 (COVID-19) is witnessing a change as we learn more about the pathophysiology and the severity of the disease. Several randomized controlled trials (RCTs) and meta-analysis have been published over the last few months. Several interventions and therapies which showed promise in the initial days of the pandemic have subsequently failed to show benefit in well-designed trials. Understanding of the methods of oxygen delivery and ventilation have also evolved over the past few months. The Indian Society of Critical Care Medicine (ISCCM) has reviewed the evidence that has emerged since the publication of its position statement in May and has put together an addendum of updated evidence. How to cite this article: Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S225–S230.

The coronavirus disease-2019 (COVID-19) pandemic has put healthcare services all over the world into a challenging situation. The contagious nature of the disease and the respiratory failure necessitating ventilatory care of these patients have put extra burden on intensive care unit (ICU) services. India has been no exception; by March 2020, the number of COVID-19 patients started increasing in India. This article describes the measures taken and challenges faced in creating ample ICU bed capacity to cater to the anticipated load of patients in the state of Delhi, India, as a result of the COVID-19 pandemic. The main challenges faced, among others, were estimating the number of ICU beds to be created; deciding on dedicated hospitals to treat COVID-19 patients; procuring ventilators, personal protective equipment, and other related material; mobilizing human resources and providing their training; and providing isolated in-house accommodations to the staff on duty. The authors acknowledge and agree that the methodology proposed in this article is but one way of approaching this difficult scenario and that there could be other, perhaps better, methods of dealing with such a problem.

Mechanical ventilation is indicated in patients with acute respiratory failure when they are unable to maintain adequate oxygenation and or remove carbon dioxide. None of the ventilatory mode can cure the disease process. However, it supports ventilation till you address the reversible primary problem. Mechanical ventilation should not be started without thoughtful consideration as tracheal intubation and ventilation are associated with significant complications.

BACKGROUND The ideal concentration of lignocaine for topical anesthesia in bronchoscopy remains investigational. In this randomized, double blind study, we compared 1% versus 2% lignocaine for topical anesthesia. METHODS Consecutive patients undergoing bronchoscopy were randomized to receive either 1% or 2% lignocaine solution by spray-as-you-go technique. All received 10% lignocaine spray to the oropharynx along with nasal 2% lignocaine gel. Nebulized lignocaine was not administered. Primary outcomes were operator-rated overall procedural satisfaction, visual analogue scale (VAS)-rated and operator-rated cough, VAS. Secondary objectives were total lignocaine dose administered, patient-rated pain on faces pain scale, cumulative dose of lignocaine and procedural complications. RESULTS A total of 500 patients (250 in each group) were randomized. Baseline characteristics were comparable. Operator-rated overall procedural satisfaction, VAS (72.05±20.16 and 72.20±21.96 in 1% and 2% group respectively; P=0.93) and operator-rated cough, VAS [1% group: 19.1 (12.6-34.6) and 2% group: 20.6 (12.5-36.9); P>0.05] were similar between the 2 groups. Cumulative dose of lignocaine used in 2% lignocaine group was greater (220.89±12.96 mg in 1% and 319.55±19.32 mg in 2% group; P

Background: There is a lack of contemporaneous data on the practices of flexible bronchoscopy in India. Aim: The aim of the study was to study the prevalent practices of flexible bronchoscopy across India. Methods: The “Indian Bronchoscopy Survey” was a 98-question, online survey structured into the following sections: general information, patient preparation and monitoring, sedation and topical anesthesia, procedural/technical aspects, and bronchoscope disinfection/staff protection. Results: Responses from 669 bronchoscopists (mean age: 40.2 years, 91.8% adult pulmonologists) were available for analysis. Approximately, 70,000 flexible bronchoscopy examinations had been performed over the preceding year. A majority (59%) of bronchoscopists were performing bronchoscopy without sedation. A large number (45%) of bronchoscopists had learned the procedure outside of their fellowship training. About 55% used anticholinergic premedication either as a routine or occasionally. Nebulized lignocaine was being used by 72%, while 24% utilized transtracheal administration of lignocaine. The most commonly (75%) used concentration of lignocaine was 2%. Midazolam with or without fentanyl was the preferred agent for intravenous sedation. The use of video bronchoscope was common (80.8%). The most common (94%) route for performing bronchoscopy was nasal. Conventional transbronchial needle aspiration (TBNA) was being performed by 74%, while 92% and 78% performed endobronchial and transbronchial lung biopsy, respectively. Therapeutic airway interventions (stents, electrocautery, cryotherapy, and others) were being performed by 30%, while endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and rigid bronchoscopy were performed by 27% and 19.5%, respectively. Conclusion: There is a wide national variation in the practices of performing flexible bronchoscopy. However, there has been a considerable improvement in bronchoscopy practices compared to previous national surveys.

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.

AIM To prospectively evaluate the reproducibility of diaphragm thickness measurement by ultrasonography at the bedside by critical care physicians in patients on invasive mechanical ventilation. METHODS In a prospective observational study of 64 invasively ventilated patients, diaphragmatic thickness measurement was taken by 2 different observers at the same site. Three measurements were taken by each observer and averaged. The intraobserver and interobserver variability was assessed by estimation of intraclass correlation coefficient. The limits of agreement were plotted as the difference between two observations against the average of the two observations in Bland and Altman analysis. RESULTS The mean diaphragm thickness at the functional residual capacity was 2.29 ± 0.4 mm and the lower limit of the normal, i.e., the 5th percentile was 1.7 mm (95%CI: 1.6-1.8). The intraclass correlation coefficient for intraobserver variability was 0.986 (95%CI: 0.979-0.991) with a P value of < 0.001. The intraclass correlation coefficient for interobserver variability was 0.987 (95%CI: 0.949-0.997) with a P value of < 0.001. In Bland and Altman analysis, both intraobserver and interobserver measurements showed high limits of agreement. CONCLUSION Our study demonstrates that the measurement of diaphragm thickness by ultrasound can be accurately performed by critical care physicians with high degree of reproducibility in patients on mechanical ventilation.

The second part of the review discusses the role of different existing imaging modalities in the evaluation of thoracic sarcoidosis, including chest radiograph, computed tomography, magnetic resonance imaging, endobronchial ultrasound, and positron emission tomography. While summarizing the advantages and pitfalls of each imaging modality, the authors propose imaging recommendations and an algorithm to be followed in the evaluation of clinically suspected case of sarcoidosis in tuberculosis-endemic regions.

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.

Background: Muscle wasting is common among critically ill patients with sepsis and has a significant effect on clinical outcome. However, appropriate tool for measurement of muscle loss is debatable. Ultrasonography (USG) has been used for objective assessment of quadriceps muscle thickness among these patients; however, there is limited data on its reliability. Aims and Objective: This study was aimed to assess the reliability of quadriceps muscle thickness as measured by critical care physicians. Methodology: This cross-sectional study included twenty patients with sepsis. Quadriceps muscle thickness was measured on right mid-thigh at a predefined point by two critical care fellows using bedside USG. Intra- and inter-observer reliability of the measurements was assessed by intra-class correlation coefficient (ICC). Results: Hundred and twenty quadriceps muscle thickness measurements, three by each of the two critical care fellows, were done in twenty patients with sepsis. First, second, and third measurements (mean ± standard deviation) taken by the first observer (RK) were 35.030 ± 3.546 mm, 35.055 ± 3.307 mm, and 35.245 ± 3.027 mm, respectively. The three values recorded by the second observer (AD) were 35.585 ± 3.746 mm, 35.1 ± 3.006 mm, and 34.89 ± 2.556 mm, respectively. ICC for observer 1 and 2 was 0.925 (95% confidence interval [CI]: 0.851–0.967) and 0.835 (95% CI: 0.689–0.925), respectively. The mean difference of measurement between two observers was 0.082 mm (95% CI: −1.194–1.031). The mean ICC (95% CI) for inter-observer reliability was 0.992 (0.979–0.997); P Conclusions: This study shows that ultrasound is a reliable tool for the measurement of quadriceps muscle thickness by critical care physicians with excellent inter- and intra-class reliability.

Background: Understanding the risk factors and microbiology of ventilator-associated pneumonia (VAP) among patients with chronic obstructive pulmonary disease (COPD) is important for the application of preventive and therapeutic interventions. Therefore, this study was planned to assess the clinical predictors and microbiological features of VAP among COPD patients. Materials and Methods: This prospective study involved patients with exacerbation of COPD who required mechanical ventilation and admitted in respiratory intensive care unit at a tertiary care teaching hospital. Various baseline demographic and clinical features were compared between patients with VAP and without VAP. Univariate and multivariable analyses were done to assess the impact of demographic and clinical features on the development of VAP. Results: The study included 100 intubated patients with age (mean ± standard deviation [SD]) of 62.45 ± 8.32 years, duration (median) of COPD of 6 years, and Acute Physiology, Age, and Chronic Health Evaluation score (mean ± SD) of 18.60 ± 4.30. In this cohort, 17 patients developed VAP. Multivariable analysis showed that Sequential Organ Failure Assessment (SOFA) score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP with odds ratio (95% confidence interval) of 2.70 (1.24, 5.63; P = 0.012), 66.96 (4.86, 922.72; P = 0.002), and 35.92 (2.84, 454.63; P = 0.006), respectively. Acinetobacter baumannii was the most frequent organism (n = 8; 47%), followed by Klebsiella pneumoniae (n = 5; 29%), Pseudomonas aeruginosa (n = 1; 6%), and Enterobacter spp. (n = 1; 6%). All organisms were multidrug resistant (MDR). Conclusions: SOFA score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP. Antimicrobial therapy for VAP should cover MDR Gram-negative organisms.

Background Delays that postpone the evaluation and management of malignancy may lead to considerable morbidity. The primary objective of this study was to assess the time required to diagnose and treat lung cancer at an Indian public referral center that predominantly serves lower-income patients. Methods A review of patients diagnosed with lung cancer between January 2008 and December 2016 was completed. We computed the median time intervals and inter-quartile ranges between symptom onset, definitive diagnostic investigation, confirmed histologic diagnosis, and chemotherapy initiation. Median intervals were correlated with baseline demographics and disease characteristics using Kruskal-Wallis test. Results One thousand, three hundred and-seventy patients were selected. A majority (94.5%) with non-small cell lung cancer were diagnosed with advanced disease. After developing symptoms, patients required 101 [56–168] days to undergo a definitive diagnostic study, 107 [60–173] days to confirm a diagnosis, and 126 [85–196.8] days to initiate treatment. Patients who were previously treated for tuberculosis required more time to receive chemotherapy compared to those who were not (187 [134–261.5] days vs. 113 [75–180] days, p Conclusion Among lower-income Indian patients, the most prominent delays occur prior to diagnosis. Efforts should be directed toward encouraging physicians to maintain a high index of clinical suspicion and educating patients to report concerning symptoms as early as possible.

Background A systematic assessment of comprehensive clinical outcomes after various therapeutic procedures for malignant central airway obstruction (CAO) is lacking. Methods Patients with symptomatic malignant CAO undergoing various therapeutic bronchoscopy procedures were assessed for symptomatic and functional improvement using the Speiser Score, spirometry, 6-minute walk distance (6MWD), and St. George Respiratory Questionnaire (SGRQ) up to 3 months after the procedures. Results A total of 83 intervention procedures were performed in 65 patients, comprising 43 (66.2%) male individuals [overall mean age, 52.4; SD, 15.4 y]. The majority of these (92.3%) was done using rigid bronchoscope under general anesthesia. Airway stenting was the most common intervention performed (56.6%), followed by mechanical debulking (26.5%), cryodebulking (6%), electrosurgical removal (4.8%), balloon dilatation (3.6%), and laser ablation (2.4%).A total of 15 complications (18.1%) were noted. Of these, 8 (53.3%) were early complications and 7 (46.7%) were late complications. Early complications included airway bleeding, hypoxia, vocal cord injury, laryngeal injury, and pneumothorax. Late complications included significant granulation tissue formation in metallic stents and lung collapse because of mucus plug.The survival rates at 4, 8, and 12 weeks were 83%, 70.7%, and 66.1%, respectively. Significant improvement was observed in dyspnea, cough, Speiser Score, 6MWD, forced expiratory volume in 1 s, forced vital capacity, and SGRQ scores at 48 hours, 4 weeks, and at 12 weeks after the procedures and no procedure-related mortality occurred. Conclusion Various therapeutic bronchoscopic interventions, including combined modalities, provide rapid and sustained improvements in symptoms, respiratory status, exercise capacity, and quality of life in malignant CAO and have a good safety profile.

How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.

BACKGROUND There is debate regarding the ideal instrument for medical thoracoscopy. The authors compared rigid mini-thoracoscopy with semirigid thoracoscopy for thoracoscopic pleural biopsy. METHODS Consecutive subjects with undiagnosed exudative pleural effusion were randomized (1:1 ratio) to mini-thoracoscopy or semirigid thoracoscopy groups. The primary objective was a comparison of the diagnostic yield of pleural biopsy. Key secondary outcomes were the comparison of sedative/analgesic dose, operator-rated and patient-rated pain on visual analog scale (VAS), operator-rated overall procedural satisfaction (VAS), pleural biopsy size, and complications between the groups. RESULTS Of the 88 screened subjects, 73 were randomized: 36 to mini-thoracoscopy and 37 to semirigid thoracoscopy. Diagnostic yield of pleural biopsy in the mini-thoracoscopy (69.4%) and semirigid thoracoscopy groups (81.1%) was similar on intention-to-treat analysis (P=0.25). Although the operator-rated overall procedure satisfaction scores were similar between groups (P=0.87), operator-rated pain [VAS (mean±SD), 43.5±16.7 vs. 31.7±15.8; P

Background and aims Data regarding trends of muscle loss on ultrasonography (USG) and its relationship with various outcomes among critically ill patients is limited. This study aimed to describe the trends of loss of muscle thickness of the arm and thigh (assessed using USG) and to determine the relationship between loss of muscle thickness and in-hospital and post-discharge outcomes. Methods Muscle thickness of 70 patients with sepsis was measured at the level of the mid-arm and mid-thigh using bedside USG on days 1, 3, 5, 7, 10 and 14 and then weekly till discharge or death. Patients were followed up for 90 days after discharge. Results The muscle thickness (mean ± SD) at the level of the mid-arm and mid-thigh on day 1 was 23.13 ± 4.83 mm and 31.21 ± 8.56 mm, respectively. The percentage muscle thickness [median (min, max)] decline at the mid-arm and mid-thigh was 7.61 (− 1.51, 32.05)% and 10.62 (− 1.48, 32.06)%, respectively on day 7 as compared to baseline (p

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.

Background: Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by deposition of lipoproteinaceous material within alveoli, with a variable clinical course. Here, we report an experience of management of PAP at our center. A systematic review of previously reported cases from India is also included in the article. Materials and Methods: This study included patients with primary PAP managed at our center from 2009 to 2015. Diagnosis of primary PAP was based on histopathologic diagnosis on bronchoalveolar lavage or transbronchial lung biopsy and absence of causes of secondary PAP. For systematic review of Indian publications, the literature search was performed using PubMed and EMBASE databases using the terms “pulmonary alveolar proteinosis'” or “alveolar proteinosis” and “India” or “Indian.” Results: During the above-specified period, five patients with diagnosis of PAP were admitted at our center. Median age of patients was 32 years (interquartile range [IQR] 30.5–59); 80% were female. Mean duration (± standard deviation) of symptoms was 6.2 (±1.79) months. Anti-granulocyte-macrophage colony stimulating factor (GM-CSF) antibodies were elevated in 4 out of 5 patients (80%). For management, whole lung lavage (WLL) was done for four patients with median volume of 32.5 (IQR 18–74) L per patient. All the patients showed significant symptomatic as well as improvement in physiological parameters. Subcutaneous GM-CSF and ambroxol were given to 3 patients and 1 patient, respectively. The median follow-up of all patients was 18 (IQR 5–44) months. A systematic review of all Indian studies of PAP revealed thirty publications. Conclusions: WLL is the most common, effective, and safe therapy in patients with PAP. GM-CSF administration is an efficacious treatment for patients with incomplete response after WLL.

Background: Self-expanding metal stents (SEMS) are a well-accepted treatment modality for malignant tracheobronchial obstruction or malignant tracheoesophageal fistulae (TEFs). The traditional approach to SEMS insertion in central airway obstruction (CAO) has been rigid bronchoscopy performed under general anesthesia. Fluoroscopic guidance is sometimes utilized. Safe and accurate placement of tracheobronchial SEMS has also been described using flexible bronchoscopy. We herein describe our experience with tracheal SEMS insertion using flexible bronchoscopy without fluoroscopic guidance. Methods: A retrospective analysis of the bronchoscopy records was undertaken for the duration June 2012 to June 2014. Patients with malignant CAO or malignant TEF who underwent tracheal SEMS insertion using flexible bronchoscopy were included. Procedures were performed under mild sedation. Fluoroscopic guidance was not utilized. Results: Eleven patients were identified. The mean age was 60.9 (12.8) years. There were 6 males and 5 female patients. Most common indication for tracheal SEMS was CAO (9/11) followed by TEF (2/11). Stent deployment could be accomplished successfully and at the desired location in all the patients. All patients reported immediate symptomatic relief. Two patients experienced peri-procedural respiratory failure that recovered within 24 h. There was no procedure related mortality or other major complications. Conclusion: Insertion of tracheal SEMS in patients with malignant CAO/TEF using flexible bronchoscopy under minimal sedation is a safe and efficacious modality that can be performed without fluoroscopic guidance.

Mycobacterium tuberculosis (M.tb) infection stimulates the release of cytokines, including interferons (IFNs). IFNs are initiators, regulators, and effectors of innate and adaptive immunity. Accordingly, the expression levels of Type I (α, β) and II (γ) IFNs, among untreated tuberculosis (TB) patients and household contacts (HHC) clinically free of TB was assessed. A total of 264 individuals (TB patients-123; HHC-86; laboratory volunteers-55; Treated TB patients-36) were enrolled for this study. IFN-α mRNA expression levels predominated compared to IFN-γ and IFN-β among untreated TB patients. IFN-α transcripts were ~3.5 folds higher in TB patients compared to HHC, (p

Background: Central airway obstruction (CAO) is a potentially lethal condition that requires urgent endobronchial intervention and may occur due to several nonmalignant causes. The effect of these interventions on clinically relevant outcomes such as symptomatic and functional status over a period of time is, however, sparsely studied. Materials and Methods: Consecutive patients with CAO due to nonmalignant causes and undergoing various therapeutic bronchoscopy procedures were evaluated. Symptoms were assessed using the Visual Analog Scale (VAS) and Speiser score, and functional status was assessed using the 6-min walk test, spirometry, and St. George Respiratory Questionnaire (SGRQ) score at baseline and after 48 h, 4 weeks, and 12 weeks postprocedure. Results: Over 2 years, 31 patients with CAO due to nonmalignant etiology underwent 41 therapeutic bronchoscopic procedures. Majority of procedures (96.8%) were done using the rigid bronchoscope under general anesthesia. Postintubation tracheal stenosis was the most common indication (32.2%). The various procedures included, controlled radial expansion balloon dilatation of the stenotic airway (53.6%), deployment of silicone stents (19.5%), and mechanical debulking of airway tumors (16.1%). Significant improvement occurred in dyspnea and cough scores and in the Speiser score from baseline to 48 h postprocedure, and further improved at 4 weeks and 12 weeks. Similarly, the 6 min walk distance, forced expiratory volume in 1 s, and SGRQ scores progressively improved from baseline to 12 weeks. Complications occurred in 26.8% of total procedures, with no procedure-related mortality. Conclusion: Therapeutic bronchoscopy interventions provide rapid and sustained benefits in symptoms and functional status of participants with CAO of nonmalignant etiology, with an acceptable safety profile.

Background and Objectives: No previous study has compared different concentrations of lignocaine for topical anesthesia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study, we compared 1% versus 2% lignocaine for topical airway anesthesia during EBUS-TBNA. Methods: In this double-blind, randomized trial, subjects were randomized to receive either 1% or 2% lignocaine for “spray-as-you-go” administration. All received combined moderate intravenous sedation (midazolam and fentanyl). Ten percent pharyngeal lignocaine spray (two sprays) and nebulized lignocaine (2.5 ml of 4% solution) were administered to all subjects. Administration of additional lignocaine was allowed at operator's discretion. The primary endpoints were operator-rated overall procedural satisfaction and cough, each assessed on visual analog scale (VAS), while the secondary outcomes included patient-rated faces pain scale scores, cumulative lignocaine dose, number of subjects receiving lignocaine >8.2 mg/kg, doses of midazolam/fentanyl between groups, and adverse events during procedure. Results: The mean (standard deviation [SD]) VAS scores for operator-rated procedure satisfaction were 64.2 (25.6) and 68.7 (23.7) in 1% and 2% group, respectively (P = 0.35). The median (interquartile range) VAS scores for operator-rated cough were 48.4 (23.9–69.9) in 1% group and 38.7 (18.6–69.5) in 2% group (P = 0.24). The mean [SD] cumulative lignocaine received in the 2% lignocaine group (248.6 [29.1] mg) was significantly greater than in 1% lignocaine group (178.5 [14.6] mg) (P < 0.01). Conclusion: One percent lignocaine is equally efficacious as 2% lignocaine for topical anesthesia during EBUS-TBNA, at a significantly lower cumulative lignocaine dose.

Background: Mini-Thoracoscope is a relatively newer rigid instrument for pleuroscopy and studies comparing its performance with other pleuroscopy instruments are lacking. This randomized trial compared “mini thoracoscopy” with Semi-Rigid thoracoscopy in undiagnosed pleural effusions. Methods: Consecutive subjects with undiagnosed exudative pleural effusion were randomized (1:1 ratio) to either of the two approaches, Mini-thoracoscopy (MT) or Semi-Rigid thoracoscopy (SRT). Procedures were performed under local anesthesia and combination moderate sedation. The primary outcome measure was the diagnostic yield between the two groups. Secondary outcomes were comparison of procedural pain, sedative doses, image quality, complications, and requirement of conversion to alternate equipment for pleural biopsy. Results: Fifty-six patients were randomized (29-MT and 27-SRT) and baseline characteristics were comparable. Diagnostic yield (MT-24/29, 82.8% and SRT-24/27, 88.9%, p=0.51) was similar between the groups. Operator rated pain, VAS (Visual analogue scale) (MT 45.0+17.8 and SRT 33.9+15.9, p=0.01) and patient rated pain, VAS (MT 44.6+18.1 and SRT 34.7+15.3, p=0.03) was greater in the MT group. Ease of maneuverability was better in the SRT group. Sedative doses, image quality, complications and ease of obtaining pleural biopsy were similar between the groups. Two patients in the MT group required conversion to SRT in view of difficulty in maneuverability. Conclusion: Mini-Thoracoscope has comparable diagnostic characteristics as compared to semirigid thoracoscopy in evaluation of undiagnosed pleural effusions but is associated with greater procedural discomfort.

Purpose of the Study: Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting. Methodology: This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV). Results: NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters ( n = 15), hypotension ( n = 6), worsening of sensorium ( n = 3), and intolerance ( n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)]. Conclusions: NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

BACKGROUND: Malnutrition is frequent in lung cancer and is measured using various tools, including the novel bioelectric impedance technique for measuring body composition. However, the validation of this technique for assessing body composition in advanced small cell lung cancer (SCLC) is untested. METHODS: Forty-one treatment naive patients (all males) and an equal number of age- and sex-matched controls were evaluated by anthropometric measurements of skinfold thicknesses and body composition parameters such as body fat%, fat mass, fat-free mass (FFM), and total body water (TBW). RESULTS: The mean (SD) age of the patient group was 55.7 (7.5) years, median pack-years was 20 (range, 0-80), and mean (SD) duration of symptoms was 152.6 (153.7) days. Median Karnofsky Performance Scale was 70 (range, 50–90). Majority of our patients (68.3%) were Stage IV followed by Stage III (31.7%). The percentage of patients with low, normal, and high body mass index (BMI) was 31.7%, 61%, and 7.3%, respectively. All components of body composition, i.e., body fat%, FFM, and TBW were significantly lower in patients compared to controls. However, the body composition in patients and controls with normal BMI was similar. The phenomenon of sarcopenia as a cause of cancer cachexia may explain these findings, whereas the combination of loss of body fat and lean body mass may lead to weight loss and reduced BMI. CONCLUSION: Our results indicate that body composition is markedly altered in Indian patients with advanced SCLC. The impact of these parameters on clinically relevant outcomes needs further evaluation.

Sarcoidosis is a multi-systemic disorder of unknown etiology, although commonly believed to be immune-mediated. Histologically, it is characterized by noncaseating granuloma which contrasts against the caseating granuloma seen in tuberculosis (TB), an infectious disease that closely mimics sarcoidosis, both clinically as well as radiologically. In TB-endemic regions, the overlapping clinico-radiological manifestations create significant diagnostic dilemma, especially since the management options are markedly different in the two entities. Part 1 of this review aims to summarize the clinical, laboratory, and imaging features of sarcoidosis, encompassing both typical and atypical manifestations, in an attempt to distinguish between the two disease entities.

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

Summary Purpose Reliability of arm muscle thickness measurement using ultrasonography (USG) by operators of varied experience is unknown. Hence, we planned this study to determine the reliability of arm muscle thickness measured using USG by 5 observers with variable experience. Materials and method This was a cross-sectional observational study which included critically ill patients with sepsis. Arm muscle thickness was measured in triplicate on Siemens ACUSON X300™ USG machine by each of 5 observers. Intra-class correlation coefficient (ICC) was computed to assess intra-observer and inter-observer variability of multiple observations. Results This study included 45 (30 – male) patients. Mean (±SD) age, APACHE and SAPS score of the participants were 54.95 (±15.97) years, 14.66 (±4.57) and 2.6 (±1.37), respectively. There were 135 observations by each observer. ICC (95%CI) for intra-observer reliability study for observer 1, 2, 3, 4, and 5 were 0.997 (0.995–0.998), 0.996 (0.993–0.998), 0.997 (0.996–0.998), 0.997 (0.994–0.998) and 0.998 (0.986–0.999), respectively. ICC (95%CI) for inter-observer reliability study for 1st, 2nd and 3rd reading were 0.963 (0.943–0.977), 0.992 (0.988–0.995) and 0.992 (0.988–0.995), respectively. Conclusions There was an excellent intra- and inter-observer agreement among 5 observers for measurement of arm muscle thickness using bedside USG among patients with sepsis.

Introduction: Pulmonary rehabilitation (PR), is an established intervention in patients with COPD. Its utility in non-cystic fibrosis bronchiectasis (NCFB) is unclear and based on limited studies. Aim: To determine efficacy of PR program in patients with NCFB. Methods: NCFB patients who had at least 2 exacerbations in 1 year and mMRC score ≥2 were recruited. Baseline evaluation was done which included 6 minute walk distance (6MWD), CPET (VO2 max), spirometry, quality of life (using the SGRQ and LCQ), depression, anxiety and stress assessment (using the DASS scale). Participants were randomly assigned to receive either PR in addition to standard care (Intervention) or standard care alone (Control) and were reassessed after 8 weeks. Results: 60 patients were randomized: 31 to intervention and 29 to control arm. 18 dropped out; 11 from intervention and 7 from control arm. The VO2 max and 6MWD increased in intervention arm by an additional 81.7ml/min (p=0.006) and 36.9m (p Conclusions: PR provides significant benefits in NCFB and should be part of routine care.