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A prospective study of 76 consecutive patients over the age of 40 years, with exudative pleural effusion, was undertaken to determine the common causes of such a clinical condition. Malignant pleural effusions were the most common in this series, found in 49 patients (64.47%), all but one being metastatic from elsewhere. Forty were secondary to a carcinoma of the bronchus, 3 from carcinoma of the breast, 1 each from carcinoma of the ovary, oesophagus, and larynx; lymphoma accounted for the remaining 2. Infective causes accounted for 24 of the effusions (31.57%). Of the infections, tuberculosis was the most common, accounting for 17 of the 24. Other infective causes included bacterial empyemas in 4, ruptured amoebic liver abscess in 2, and actinomycosis in 1. Pancreatitis, pulmonary thromboembolism, and a post-cardiotomy syndrome were diagnosed in 1 patient each, while the diagnosis remained unknown in the remaining 5 patients. In 2 patients the diagnosis was made on autopsy.

We present a rare disease condition Hermansky-Pudlak syndrome in a 33-year-old male. He was born of a consanguineous marriage, had occulo-cutaneous albinism, nystagmus, decreased visual acuity, refractory errors, pulmonary fibrosis and granulomatous inflammation of the colon. In spite of all the classical features of this genetic disorder he was labeled to have disseminated tuberculous infection with a drug resistant strain for many years till the actual diagnosis was made on the basis of a strong clinical suspicion. We report this rare condition which might be misdiagnosed as tuberculosis.

A 75-year-old female was commenced on sildenafil for the treatment of pulmonary arterial hypertension (PAH) secondary to chronic obstructive pulmonary disease (COPD). She reported blurring of vision within 72 hours after starting treatment and was found to have a central retinal vein occlusion (CRVO). Such an occurrence is the second case reported to date, and we review the possible mechanisms and literature on the subject.

Methods ISMAR is an international, multicenter, non-interventional, cross-sectional study conducted in adults and children (≥ 6 years) with physician diagnosis-AR of at least 1 year of duration. Physicians recruited consecutive patients to whom the ISMAR questionnaire was administered. Data collection was performed during a single visit. Other 2 additional documents (the investigator’s questionnaire and Case Record Form) were also filled in. Statistical analysis was descriptive. For statistical inferences, Student tor Wilcoxon test were performed according to the variables normality. Herein we show the results on Patient Optimal Management. Patients fulfilling the following criteria were considered as optimally managed: Patient education, environmental control and allergen avoidance Optimal pharmacological treatment according to ARIA guidelines Results Two thousand three hundred patients (2298 were analyzed), mean age 28.8 ± 15.9 years, 54.4% of males were included in 5 new countries and in 4 countries (new centres) that already participated in ISMAR phase 1. The nasal symptoms frequency was 4 days per week (29.1%) and > 4 consecutive weeks (21.8%) [N=2207]. 85.7% of patients had never smoked. Current smokers suffered most commonly of persistent rhinitis (61.3%). Patients reported having within the past 12 months, most frequently: recurrent cough (57.1%), nocturnal cough (40.8%), recurrent dyspnea/breathlessness (36.5%), dyspnea/breathlessness after exercise (33.1%), recurrent wheezing (32.1%), cough after exercise (29.8%), nocturnal dyspnea/breathlessness (29.5%). AR symptoms impaired sleep (63.5%), mood (61.9%), physical activities (50.4%), and working performance (42.1%). 96.3% of patients received recommendations to avoid allergens and irritants. 96.6% were receiving AR treatment, mainly antihistamines and nasal corticosteroids but also anti-leukotrienes and nasal and oral decongestants. 55.8% of patients had an optimal treatment. Patients with a frequency of nasal symptoms > 4 days per week and > 4 consecutive weeks and those with recurrent dyspnea/breathlessness appeared as more frequently optimally managed (p

The most hazardous manifestation of pulmonary alveolar proteinosis is progressive hypoxia for which bronchopulmonary lavage (BPL) is the single most effective treatment. Unfortunately this procedure under general anesthesia itself increases the risk of hypoxia due to the need for one lung ventilation. It was therefore considered interesting to report the successful anaesthetic management of a patient with pulmonary alveolar proteinosis for Bronchopulmonary lavage.

To evaluate the utility of bronchoalveolar lavage (BAL) in immunocompromised patients.We studied BAL cytology and microbiological culture in 16 kidney transplant recipients (Group A), 14 dialysis patients (Group B) and eight HIV positive patients (Group C) suspected of having pulmonary infections. A group of 21 individuals without pulmonary diseases were studied as controls.A comparison of the cytological profile in controls and study groups showed that percentages of lymphocytes and neutrophils were significantly increased in all three patient groups as compared to controls, BAL bacterial cultures were positive in 4, 3 and 4 cases of Group A, B and C, respectively. Direct examination of BAL cytosmears helped in detecting cytomegalovirus inclusions, acid fast bacilli and Pneumocystis carinii in 3, 2 and 5 cases of Group A, B and C, respectively though microbial cultures were negative. The sensitivity of BAL cytology was found to be 76.3%, whereas that of microbial culture was only 31.5%. The diagnostic yield of BAL was 68.75%, 71.42% and 100% in the Groups A, B and C, respectively, while it was 76% when all three groups were considered together. BAL cytology yielded the diagnosis in 47.36% of cases, a combination of BAL cytology and culture in 23.68% and culture alone in 5.3% of cases.BAL is useful relatively non-invasive investigative tool in the rapid diagnosis of infections in immunocompromised patients. BAL cytology was found to be more useful than microbial cultures.

Background: Asthma management has been fraught with several challenges especially for partly or uncontrolled cases. Incremental dosage strategy with salmeterol, fluticasone propionate combination offers stable yet effective control of symptoms preventing further exacerbations. However, there is limited evidence available on the need and safety profile of this incremental dosage strategy with the combination especially in Indian settings. To examine the safety and adverse clinical outcomes of Airtec SF when prescribed in patients with well- or poorly controlled persistent asthma. Methods: Based on the principle of prescription event monitoring (PEM) for safety reporting, this study was conducted at 20 centers across India. PEM study booklets with study questionnaire were provided to capture information related to adverse “events” during the observation period of 30 days. Results: Data of 384 patients were analyzed, with a mean age 44.5 years. 39% (n=150) were newly diagnosed and 61% (n=234) being in poorly controlled asthma status (i.e., partly or uncontrolled asthma). Of them, 42% (161), 44% (n=169) and 14% (54) patients were diagnosed with mild, moderate or severe persistent asthma, respectively. These were prescribed with metered-dose inhaler (n=187) or dry powder inhaler (n=197) formulations. 56% (n=216) patients suffered from concomitant allergic rhinitis. Among newly diagnosed patients with moderate to severe asthma dosage were tapered in 5.5% (n=3) cases. Dosage consistency was well-maintained in 98.2% (n=155) among partial or uncontrolled asthmatics with moderate to severe asthma with exacerbation rate of 1.9% (n=3). Adverse events including infective pneumonitis and upper respiratory tract infection were transient with none requiring treatment withdrawal. Conclusion: Use of Airtec SF was safe and well-tolerated with a negligible rate of exacerbations in Indian population especially amongst poorly controlled asthma patients.

The effect of inhalation of ipratropium bromide was evaluated in 20 patients with bronchial asthma. It was observed that there was no significant improvement in the forced vital capacity and the forced expired volume in one second, while there was significant improvement in the peak expiratory flow rate (PEFR) measured at 9 pm, after inhalation of 2 puffs of ipratropium bromide aerosol (0.02mg/puff) three to four times a day for 2 weeks. Since PEFR is a measure of large airway function and cholinergic mechanisms are primarily involved for airflow obstruction at large airways, improvement in PEFR by ipratropium bromide highlights its role as a useful bronchodilator in patients in whom vagal reflexes are responsible for the provocation of bronchoconstriction.

The most hazardous manifestation of pulmonary alveolar proteinosis is progressive hypoxia for which bronchopulmonary lavage (BPL) is the single most effective treatment. Unfortunately this procedure under general anesthesia itself increases the risk of hypoxia due to the need for one lung ventilation. It was therefore considered interesting to report the successful anaesthetic management of a patient with pulmonary alveolar proteinosis for Bronchopulmonary lavage.

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.In developing countries, the proportion of Pneumocystis carinii pneumonia (PCP) cases, compared to other opportunistic infections associated with AIDS, is low partly because of underdiagnosis. PCP cases are reported that were diagnosed by bronchoalveolar lavage (BAL) cytology and transbronchial lung biopsy (TBLB) in 3 out of 5 HIV-positive adult patients presenting with interstitial pneumonitis at the Department of Chest Medicine, KEM Hospital, Bombay. One of these patients was serologically positive for HIV at the time of presentation and the remaining 2 patients were detected to be HIV-positive on follow-up after the diagnosis had been established. All patients had elevated erythrocyte sedimentation rate. CD4+ lymphocyte analysis was done in 1 patient and revealed 360 CD4+ cells/cu. mm. BAL cytology using Giemsa stained smears confirmed the presence of cysts diagnostic of Pneumocystis carinii. TBLBs of the 3 patients who revealed P. carinii in their BAL fluid also evinced foamy intra-alveolar eosinophilic exudates, and the GMS stain showed the presence of ovoid or cup-shaped structures consistent with P. carinii within these exudates. Biopsies from the 2 PCP-negative, HIV-positive patients showed evidence of interstitial pneumonitis. All 3 patients were treated with cotrimoxazole (20 mg/kg body weight). Only 1 patient recovered and was discharged; another patient improved with treatment and was started on cefotaxime (50 mg/kg body weight) and amikacin (15 mg/kg body weight), but died after jugular vein cannulation. The third patient developed cryptosporidial diarrhea and died. The remaining 2 PCP-negative patients with nonspecific interstitial pneumonitis treated with prednisolone and bronchodilators recovered and were discharged from the hospital. BAL cytology and TBLB were useful tools in detecting PCP, one of the few treatable AIDS-related infections.

The report describes the development of an action plan for air quality improvement in Greater Bombay, based upon the assessment of emissions and air quality in the metropolitan area, population exposure and health effects (damage), the assessment of costs related to the damage and to a number of proposed abatement measures, and a cost-benefit analysis.

To study the clinical profile and cholinesterase levels of subjects of organophosphate and carbamate poisoning and to identify those subjects who would require ventilatory support.Prospective, observational study.Intensive care unit of a tertiary care urban hospital.Fifty-two patients admitted with a diagnosis of organophosphate or carbamate poisoning.Subject survival and ventilator requirement.Treatment with atropine and pralidoxime and mechanical ventilation for patients with respiratory failure. Clinical features were monitored at every stage, and blood for plasma and red blood cell cholinesterase levels was collected on admission.According to the ingested poison, subjects were divided into four groups: organophosphates (13 subjects), mixed organophosphate and carbamate (18), carbamates (13), and a fourth miscellaneous group (8). Dyspnea and vomiting were the most common symptom and miosis and cyanosis were the most frequently observed signs. Plasma and red cell cholinesterase levels were lowest in the mixed poison group and highest in the carbamate group. Twenty-seven subjects developed Type I respiratory failure and 7 had Type II respiratory failure. Mechanical ventilation was required in 31 subjects. Overall 33 subjects survived. A scoring system, on a point scale of 16, was developed using miosis, unconsciousness, fasciculations, and plasma cholinesterase levels to predict ventilator requirement.This study helps to identify at an early stage those patients with organophosphate or carbamate poisoning who would ultimately require ventilatory support. We found miosis, unconsciousness, fasciculations, and a low plasma cholinesterase level to be of greatest predictive value.

A prospective study of 76 consecutive patients over the age of 40 years, with exudative pleural effusion, was undertaken to determine the common causes of such a clinical condition. Malignant pleural effusions were the most common in this series, found in 49 patients (64.47%), all but one being metastatic from elsewhere. Forty were secondary to a carcinoma of the bronchus, 3 from carcinoma of the breast, 1 each from carcinoma of the ovary, oesophagus, and larynx; lymphoma accounted for the remaining 2. Infective causes accounted for 24 of the effusions (31.57%). Of the infections, tuberculosis was the most common, accounting for 17 of the 24. Other infective causes included bacterial empyemas in 4, ruptured amoebic liver abscess in 2, and actinomycosis in 1. Pancreatitis, pulmonary thromboembolism, and a post-cardiotomy syndrome were diagnosed in 1 patient each, while the diagnosis remained unknown in the remaining 5 patients. In 2 patients the diagnosis was made on autopsy.

With mucosal inflammation contributing to the pathogenesis of asthma, it is increasingly accepted that long term steroid inhalers may induce remission in chronic long standing asthmatics. The present study involved 44 stable asthmatics who were randomly given either beclomethasone dipropionate inhaler (50 ug) 2 puffs qds or salbutamol inhaler (100 mcg) 2 puffs tds in addition to their oral bronchodilators. Pulmonary function testing, bronchoalveolar lavage and complete blood count were done at basal and weekly intervals and at the end of the study. The absolute eosinophil count showed a significant drop in the beclomethasone group as compared to the salbutamol group. Serial lung functions showed a significant improvement in the pre-bronchodilator PEFR and the pre-bronchodilator FVC in the beclomethasone group as compared to the salbutamol group. There was no significant change in the lavage eosinophil count pre and post-bronchodilator in both groups. Steroid inhalers are thus useful in long term management of bronchial asthma especially with respect to reducing bronchodilator requirement.

Cardiopulmonary exercise testing has a definitive place in objective evaluation of the subjective sensation of breathlessness. In the present study 21 patients with COPD, 10 with ILD and 17 normals were subjected to stage 1 exercise testing and correlations were sought between Vo2 and work, FVC, FeV1, Ve, respiratory rate and tidal volume and between VCO2 and work. In COPD and ILD the Vo2 correlated with work, Fev1, Fvc and Ve whereas in normals it correlated with the VE but not with the FeV1 and FVC. In COPD VO2 correlated with TV though this was not the case in ILD. Thus stage 1 exercise testing can be a useful additional method to assess the disability in COPD and ILD although differentiation between these two respiratory diseases on basis of exercise testing alone may not be possible.

When there is an exudative pleural effusion often both the parietal and the visceral pleura are affected, but the usual practice is to perform a percutaneous parietal pleural biopsy alone for diagnosis. Percutaneous visceral pleural biopsy was carried out in 20 patients with exudative pleural effusions with fenestrated cup biopsy forceps. In all 20 biopsies pleural tissue was obtained and it was diagnostic in 19 cases. The procedure is painless and appears safe.

The effect of inhalation of ipratropium bromide was evaluated in 20 patients with bronchial asthma. It was observed that there was no significant improvement in the forced vital capacity and the forced expired volume in one second, while there was significant improvement in the peak expiratory flow rate (PEFR) measured at 9 pm, after inhalation of 2 puffs of ipratropium bromide aerosol (0.02mg/puff) three to four times a day for 2 weeks. Since PEFR is a measure of large airway function and cholinergic mechanisms are primarily involved for airflow obstruction at large airways, improvement in PEFR by ipratropium bromide highlights its role as a useful bronchodilator in patients in whom vagal reflexes are responsible for the provocation of bronchoconstriction.

Bromhexeine has been widely used as an adjunct in the management of lower respiratory infections and is useful in altering the physical characteristics of sputum. Its effect on the sputum penetration of an antibiotic has been sparsely studied. The present study highlights the improvement in sputum amoxycillin (amoxy) levels when a combination tablet, amoxy 500 mg plus bromhexeine 8 mg, is administered as compared to plain amoxy 500 mg. Sputum amoxy levels were significantly higher in the combination group (0.674 +/- 0.588 micrograms ml-1) as compared to 0.272 +/- 0.19 micrograms ml-1 in the amoxy group (P = 0.028). The clinical responses assessed by the physician as well as the patient were significantly better in the amoxy plus bromhexeine group as compared to the amoxy group. The radiological and bacteriological responses were similar in both groups. There was no increase in the side-effects due to bromhexeine and, overall, its use can be recommended in the treatment of acute lower respiratory infections.

Bronchiectasis, which is a sequel to childhood infection, is characterized by lung function decline akin to that in the general population (1,2). Bronchiectasis in cystic fibrosis is a consequence of altered mucus rheology, which predisposes the airway to mucoid impaction and recurrent lower respiratory infection. The pathology in cystic fibrosis is widespread and constantly active compared to bronchiectasis. This can cause a faster decline of lung function in cystic fibrosis. The goal of this report was to compare lung function decline in cystic fibrosis and bronchiectasis.

The experience of the intensive respiratory care in 930 cases treated from 1983 for 4 years and in 404 cases over the next 2 years is reported. The background operational problems are stressed. Those between age 10 and 50 years did significantly better (p less than 0.05). The survival over the first 4 years in IPPR cases was 16.3% and in non IPPR group 71.8%; over the next 2 years, the former group, survival was 32.4 and 36.3%. The survival in asthmatic patients was high (76%). In cases with organophosphorus poisoning (without IPPR), survival was 81% while in IPPR group it was 29%. In 1988, the results in this group were better due to more aggressive management. In autopsy data on 85 cases, infection was not a major feature in those dying within 24 hours. The survival in COPD cases showed significant relation to age (p less than 0.05), initial arterial pO2 below 60 mm (p less than 0.01) and arterial pH below 7.3 (p less than 0.01). In cases with pneumonia (also asthma) younger cases did better (p less than 0.05) as also those with pneumonia and initial pO2 above 60 mm (p less than 0.01) and pH above 7.3 (p less than 0.001). When pneumonia was community acquired, survival (64.8%) was better than when it was hospital acquired (24%; p less than 0.01). Only the need for IPPR affected survival in trauma group. The major cause of death was infection with Klebsiella, Pseudomonas, Staphylococci and other gram--ve organisms. It is concluded that with proper planning and training, the IRCU does provide a useful mode of treatment in selected patients with respiratory problems.