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Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a real-time, minimally invasive procedure for sampling intrathoracic lymph nodes. Herein, we discuss EBUS-guided procedures, their benefits, and drawbacks in diagnosing sarcoidosis., Areas Covered: We first describe the utility of various endosonographic imaging techniques like B-mode, elastography, and doppler imaging. We then review the diagnostic yield and safety of EBUS-TBNA and compare it with the other available diagnostic modalities. Subsequently, we discuss the technical aspects of EBUS-TBNA influencing the diagnostic yield. Recent advances in EBUS-guided diagnostics like EBUS-guided intranodal forceps biopsy (EBUS-IFB) and EBUS-guided transbronchial mediastinal cryobiopsy (EBMC) are reviewed. Finally, we summarize the advantages and disadvantages associated with EBUS-TBNA in sarcoidosis and provide an expert opinion on the optimal use of this procedure in patients with suspected sarcoidosis., Expert Opinion: EBUS-TBNA is a minimally invasive, safe procedure with a good diagnostic yield, and should be the preferred diagnostic modality for sampling intrathoracic lymph nodes in patients with suspected sarcoidosis. For optimal diagnostic yield, EBUS-TBNA should be combined with endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB). Newer endosonographic techniques like EBUS-IFB and EBMC might obviate the need for EBB and TBLB due to their superior diagnostic yield.

Background: Whether chronic pulmonary aspergillosis (CPA) has different immunophenotypes remains unknown., Objective: To identify different CPA immunophenotypes using cluster analysis., Methods: We used a subject-centred multivariate clustering approach without prior assumptions to identify CPA phenotypes. We retrospectively included the data of treatment-naïve subjects with CPA and excluded subjects with asthma and allergic bronchopulmonary aspergillosis (ABPA). We performed a scalable two-step cluster analysis using the log-likelihood distance measures to identify CPA phenotypes based on the blood immunological profile (total IgE, eosinophil count and Aspergillus-specific IgE and IgG)., Results: We included 351 CPA subjects and found two clusters. Cluster 2 (n = 118) had significantly higher serum total IgE, peripheral blood eosinophil count, and serum A. fumigatus-specific IgE and IgG than cluster 1 (n = 233). Cluster 2 subjects had a lower FEV1:FVC ratio on spirometry and were more likely to have a fungal ball (88 [74.6%] vs. 145 (62.2%), p = .023) on the CT thorax than cluster 1. After treatment discontinuation, cluster 2 had a longer median (interquartile range) time to relapse than cluster 1 (11.5 [7.3-27.4] vs. 4 [1.1-8.9] months, p = .005)., Conclusion: We identified two distinct CPA phenotypes, type-2 dominant and non-type-2, with different clinical and radiological findings and treatment outcomes. Future studies should confirm our findings and investigate different treatment strategies based on CPA phenotypes., (© 2022 Wiley-VCH GmbH.)

Background : The prevalence of aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) in asthmatic children remains unclear. Objective : To systematically review the literature to estimate the prevalence of AS and ABPA in children with bronchial asthma. Methods : We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in pediatric asthma. The primary outcome was to assess the prevalence of AS, while the secondary outcome was to evaluate the prevalence of ABPA. We pooled the prevalence estimates using a random effects model. We also calculated the heterogeneity and publication bias. Results : Of the 11,695 records retrieved, 16 studies with 2468 asthmatic children met the inclusion criteria. Most studies were published from tertiary centers. The pooled prevalence of AS in asthma (15 studies; 2361 subjects) was 16.1% (95% confidence intervals [CI], 9.3-24.3). The prevalence of AS was significantly higher in prospective studies, studies from India, and those from developing countries. The pooled prevalence of ABPA in asthma (5 studies; 505 children) was 9.9% (95% CI, 0.81-27.6). There was significant heterogeneity and publication bias for both outcomes. Conclusions : We found a high prevalence of AS and ABPA in asthmatic children. There is a need for community-based studies from different ethnicities using a standard methodology to ascertain the true prevalence of AS and ABPA in pediatric asthma.

Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature., Case Description and Systematic Review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26; 19.2%) or bronchoscopic instillation (1/26; 3.8%) of amphotericin B and surgery (6/26; 23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis., Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible., (© 2022 Wiley-VCH GmbH.)

Background: Whether off-site evaluation of slides by a cytologist viewing the images shared by WhatsApp improves the on-site evaluation by a pulmonologist (P-ROSE) remains unknown. This study's objective was to compare the sensitivity of P-ROSE and WHOSE for adequacy and diagnosis of cytology specimens obtained by endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA)., Materials and Methods: We retrospectively reviewed our bronchoscopy database to identify subjects who underwent EBUS-TBNA for lymph node sampling and had reports of P-ROSE and WHOSE. We collected data on the adequacy of samples as reported by the pulmonologist (P-ROSE), remotely by the cytologist (WHOSE), and finally after detailed cytologic evaluation. The study's primary outcome was to assess the increment in sensitivity for adequacy and diagnostic category (using the final cytology report as reference) by incorporating WHOSE., Results: We included 264 (P-ROSE, n = 184; WHOSE, n = 80) subjects. The sensitivity (95% CI) for sample adequacy by P-ROSE and WHOSE was 65.3% (57.9%-72%) and 92% (83.6%-96.2%), respectively. There was a 26.6% (95% CI, 16%-35.2%) increment in the sensitivity for adequacy. The sensitivity (95% CI) for diagnosis by P-ROSE and WHOSE was 53.9% (46%-61.1%) and 89.8% (79.5%-95.3%), respectively. There was a 35.9% (95% CI, 23.4%-45%) increment in the sensitivity for diagnosis with WHOSE. The agreement between P-ROSE and final cytology in adequacy was poor (κ = -0.023, p = 0.616). The agreement between WHOSE and final cytology was moderate for adequacy (κ = 0.491, p = <0.001)., Conclusion: We found WHOSE significantly improves the performance of P-ROSE for rapid assessment of cytology specimens obtained by EBUS-TBNA., (© 2022 John Wiley & Sons Ltd.)

Objective: The diagnostic performance of pleural fluid interleukins as potential biomarkers for tuberculous pleural effusion (TPE) remains unclear. We assessed the diagnostic accuracy of various interleukins in the pleural fluid for TPE and evaluated their ability to differentiate TPE from other effusions., Methods: We queried the PubMed and Embase databases for studies indexed till October 2021. We included studies that (a) provided information regarding sensitivity and specificity of pleural fluid interleukins for diagnosing TPE, or (b) compared pleural fluid interleukin levels between TPE and malignant or parapneumonic effusions. We used hierarchical summary receiver operating characteristic plots to model summary sensitivity and specificity. Random effects modeling was employed to pool standardized mean differences (SMD) across descriptive studies comparing TPE and other effusions., Results: We included 80 publications in our review; most were small and of poor quality. All interleukins except interleukin-27 (interleukins 1-beta, 2, 4, 6, 8, 10, 12, 12p40, 13, 18, 33) showed poor diagnostic accuracy and inconsistent discrimination of TPE from other effusions. The summary estimates for sensitivity, specificity, and diagnostic odds ratio were 0.94 (95 % CI 0.85-0.98), 0.97 (95 % CI 0.93-0.99), and 507.13 (95 % CI 130.66-1968.34) respectively for pleural fluid interleukin-27. Mean pleural fluid interleukin-27 levels in TPE were significantly higher than malignant (summary SMD 3.72, 95 % CI 2.81-4.63) or parapneumonic (summary SMD 2.45, 95 % CI -1.80-3.09) effusions., Conclusion: Pleural fluid interleukins are poor diagnostic biomarkers for TPE. Only pleural fluid interleukin-27 exhibited good accuracy in diagnosing TPE and needs further evaluation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Advancements in the intensive care unit (ICU) have improved critically ill subjects' short-term outcomes. However, there is a need to understand the long-term outcomes of these subjects. Herein, we study the long-term outcomes and factors associated with poor outcomes in critically ill subjects with medical illnesses., Materials and Methods: All subjects (≥12 years) discharged after an ICU stay of at least 48 hours were included. We evaluated the subjects at 3 and 6 months after ICU discharge. At each visit, subjects were administered the World Health Organization Quality of Life Instrument (WHO-QOL-BREF) questionnaire. The primary outcome was mortality at 6 months after ICU discharge. The key secondary outcome was quality of life (QOL) at 6 months., Results: In total, 265 subjects were admitted to the ICU, of whom 53 subjects (20%) died in the ICU, and 54 were excluded. Finally, 158 subjects were included: 10 (6.3%) subjects were lost to follow-up. The mortality at 6 months was 17.7% (28/158). Most subjects [16.5% (26/158)] died within the initial 3 months after ICU discharge. Quality of life scores were low in all the domains of WHO-QOL-BREF. About 12% ( n = 14) of subjects could not perform the activity of daily living at 6 months. After adjusting for covariates, ICU-acquired weakness at the time of discharge (OR 15.12; 95% CI, 2.08-109.81, p <0.01) and requirement for home ventilation (OR 22; 95% CI, 3.1-155, p <0.01) were associated with mortality at 6 months., Conclusion: Intensive care unit survivors have a high risk of death and a poor QOL during the initial 6 months following discharge., How to Cite This Article: Kodati R, Muthu V, Agarwal R, Dhooria S, Aggarwal AN, Prasad KT, et al . Long-term Survival and Quality of Life among Survivors Discharged from a Respiratory ICU in North India: A Prospective Study. Indian J Crit Care Med 2022;26(10):1078-1085., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: Whether sonographic features of mediastinal lymph nodes can differentiate malignancy from tuberculosis remains unclear., Research Design and Methods: We retrospectively identified subjects with a confirmed diagnosis of tuberculosis or malignancy on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Our primary objective was to compare the endosonographic characteristics of lymph nodes on EBUS between tuberculosis and malignancy. Our secondary objective was to assess the diagnostic performance of endosonographic characteristics in predicting malignancy., Results: We included 774 subjects (1,498 lymph nodes) with a confirmed diagnosis of tuberculosis (n = 497) or malignancy (n = 277). Distinct lymph node margins (84.1% vs. 93.8%, P < 0.001) and coagulation necrosis sign (11.2% vs. 29.8%, P < 0.001) were less common in malignancy than tuberculosis. The absence of central hilar structure had the highest sensitivity (92.1%) for malignancy. Endosonographic characteristics had poor specificity for malignancy(round shape and coagulation necrosis sign, 77.3% and 70.2%. In multivariate analysis, coagulation necrosis sign was associated with a lower odds of malignancy (odds ratio 0.45 [95% confidence intervals, 0.21-0.95])., Conclusions: Endosonographic characteristics, such as round shape and the coagulation necrosis sign, are not specific for malignancy in high tuberculosis prevalence areas.

Background: The diagnostic accuracy of immunoassays versus immunoprecipitation methods for detecting A.fumigatus-specific IgG in patients with allergic bronchopulmonary aspergillosis (ABPA) complicating asthma remains unclear., Methods: We performed a systematic review to identify studies describing both the methods in the same ABPA subjects. We assessed study quality using the QUADAS-2 tool. We derived the relative sensitivity and specificity using the HSROC meta-regression model. We calculated the number-needed-to-test using an immunoassay to detect one additional positive test in ABPA., Results: Our search yielded 20 studies (796 ABPA and 929 controls). The studies had a high risk of bias. The summary estimates for sensitivity and specificity of immunoprecipitation methods were 68.6% (95% CI, 48.4-83.5) and 93.8% (95% CI, 83.6-97.8), respectively, while for immunoassays they were 85.2% (95% CI, 73.3-92.3) and 84.6% (95% CI, 76.0-90.5), respectively. The relative sensitivity and specificity of immunoassays compared to immunoprecipitation tests were 1.29 (95% CI, 1.1-1.6) and 0.91 (95% CI, 0.85-0.97), respectively. The automated immunoassays (1.77; 95% CI, 1.1-2.8) had better relative sensitivity than the manual (1.1; 95% CI, 1.02-1.18) assays compared to immunoprecipitation. The relative specificity of manual immunoassays (0.95; 95% CI, 0.91-0.99) was significantly lower, while that of automated (0.88; 95% CI, 0.77-1.0) assays was lower but not statistically different. One additional positive result was detected for every six (95% CI, 5-7) tests performed with immunoassay (versus immunoprecipitation)., Conclusion: Compared to immunoprecipiation methods, automated immunoassays have higher sensitivity and similar specificity, manual immunoassays have higher sensitivity and lower specificity, while automated immunoassays have higher sensitivity and similar specificity for detecting A.fumigatus-IgG in patients with ABPA. [www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=309864]., (© 2022 Wiley-VCH GmbH.)

Objective: Pleural fluid lysozyme (LP) and its ratio to serum lysozyme (LP/LS) have been proposed as potential biomarkers for diagnosing tuberculous pleural effusion (TPE). We assessed the diagnostic accuracy of LP and LP/LS for TPE and evaluated their ability to differentiate TPE from other effusions., Methods: We queried the PubMed and Embase databases for studies indexed until October 2021. We included studies that (a) provided information regarding the sensitivity and specificity of LP or LP/LS for the diagnosis of TPE, or (b) compared LP or LP/LS between TPE and malignant or parapneumonic effusions. We used hierarchical summary receiver operating characteristic plots to model summary sensitivity and specificity. Random effects modeling was employed to pool standardized mean differences (SMD) across descriptive studies comparing TPE and other effusions., Results: We included 11 publications in our review, most of which were small and of poor quality. The summary estimates for sensitivity, specificity, and diagnostic odds ratio (DOR) were 0.94 (95% confidence interval [CI] 0.53-1.00), 0.89 (95% CI 0.63-0.97), and 129.88 (95% CI 6.26-2695), and 0.98 (95% CI 0.58-1.00), 0.91 (95% CI 0.84-0.96), and 708.47 (95% CI 11.42-43946), respectively, for LP and LP/LS. Mean LP and LP/LS in TPE were significantly higher than in malignant effusions (summary SMD 1.51 [95% CI 1.04-1.98] and 1.77 [95% CI 1.31-2.22], respectively), and parapneumonic effusions (summary SMD 0.86 [95% CI 0.51-1.22] and 1.15 [95% CI 0.64-1.66], respectively)., Conclusion: There is low-quality evidence of good diagnostic accuracy for both LP and LP/LS in identifying TPE, the latter being marginally superior., Competing Interests: None

Background and Objective: The epidemiology of interstitial lung diseases (ILDs) in developing countries remains unknown. The objective of this study was to estimate the incidence, prevalence, and national burden of ILDs in India., Methods: Data of consecutive subjects (aged >12 years) with ILDs included in a registry between March 2015 and February 2020 were analyzed retrospectively. The proportion of each ILD subtype was determined. The crude annual incidence and prevalence of ILDs for our region were estimated. Subsequently, the primary estimates of the national annual incident and prevalent burden of ILD and its subtypes were calculated. Alternative estimates for each ILD subtype were calculated using the current and a large, previous Indian study (n = 1,084). Data were analyzed using SPSS version 22 and are presented descriptively., Results: A total of 2,005 subjects (mean age, 50.7 years; 47% men) were enrolled. Sarcoidosis (37.3%) was the most common ILD subtype followed by connective tissue disease (CTD)-related ILDs (19.3%), idiopathic pulmonary fibrosis (IPF, 17.0%), and hypersensitivity pneumonitis (HP, 14.4%). The crude annual incidence and prevalence of ILDs were 10.1-20.2 and 49.0-98.1, respectively per 100,000 population. The best primary estimates for the crude national burden of all ILDs, sarcoidosis, CTD-ILD, IPF, HP, and other ILDs (in thousands) were 433-867, 213-427, 75-150, 51-102, 54-109, and 39-78. The respective alternative estimates (in thousands) were sarcoidosis, 127-254; CTD-ILD, 81-162; IPF, 46-91; HP, 130-261; other ILDs, 49-98., Conclusion: In contrast to developed countries, sarcoidosis and HP are the ILDs with the highest burden in India., Competing Interests: The authors have declared that no competing interests exist.

Objective: We compared diagnostic accuracy of pleural fluid Xpert MTB/RIF (Xpert) and Xpert MTB/RIF Ultra (Ultra) assays for diagnosing tuberculous pleural effusion (TPE), through systematic review and comparative meta-analysis., Methods: We searched PubMed and Embase databases for publications reporting diagnostic accuracy of Xpert or Ultra for TPE. We used bivariate random-effects modeling to summarize diagnostic accuracy information from individual studies using either mycobacterial culture or composite criteria as reference standard. We performed meta-regression through hierarchical summary receiver operating characteristic (HSROC) modeling to evaluate comparative performance of the two tests from studies reporting diagnostic accuracy of both in the same study population., Results: We retrieved 1097 publications, and included 74 for review. Summary estimates for sensitivity and specificity for Xpert were 0.52 (95% CI 0.43-0.60, I2 82.1%) and 0.99 (95% CI 0.97-0.99, I2 85.1%), respectively, using culture-based reference standard; and 0.21 (95% CI 0.17-0.26, I2 81.5%) and 1.00 (95% CI 0.99-1.00, I2 37.6%), respectively, using composite reference standard. Summary estimates for sensitivity and specificity for Ultra were 0.68 (95% CI 0.55-0.79, I2 80.0%) and 0.97 (95% CI 0.97-0.99, I2 92.1%), respectively, using culture-based reference standard; and 0.47 (95% CI 0.40-0.55, I2 64.1%) and 0.98 (95% CI 0.95-0.99, I2 54.8%), respectively, using composite reference standard. HSROC meta-regression yielded relative diagnostic odds ratio of 1.28 (95% CI 0.65-2.50) and 1.80 (95% CI 0.41-7.84) respectively in favor of Ultra, using culture and composite criteria as reference standard., Conclusion: Ultra provides superior diagnostic accuracy over Xpert for diagnosing TPE, mainly because of its higher sensitivity., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: None

Background: Chronic pulmonary aspergillosis has a 5-year mortality of 50-80% globally, and the optimal duration of treatment for chronic pulmonary aspergillosis remains unclear. We aimed to compare the effect of 6-months of oral itraconazole with 12-months of oral itraconazole on chronic pulmonary aspergillosis clinical outcomes., Methods: In this single-centre, open-label, randomised controlled trial conducted in one chest clinic in Chandigarh, India, we screened consecutive patients with chronic pulmonary aspergillosis who were naive to antifungal treatment and randomised eligible patients, using block randomisation, to receive a starting dose of 400 mg/day of oral itraconazole for either 6 months or 12 months. There was no masking of participants or investigators. We excluded patients who were unable to provide informed consent; had an intake of any antifungal drugs for more than 3 weeks in the preceding 6 months; had active Mycobacterium tuberculosis or non-tuberculous mycobacterial pulmonary disease; and had allergic, subacute, or invasive forms of aspergillosis. The primary outcome was the proportion of patients having relapse 2 years after treatment initiation. We performed an intention-to-treat analysis for all outcomes. The study is registered with ClinicalTrials.gov, NCT03920527., Findings: We recruited participants between July 1, 2019, and Aug 31, 2021. We screened 250 patients, of which 164 were included in the trial. 81 patients were randomised to the 6-month group and 83 patients were randomised to the 12-month group. The study population was 78 (48%) women and 86 (52%) men, and the mean age of participants was 44·3 (SD 13·3) years. The proportion of patients experiencing relapse was significantly lower in the 12-month group, 31 (38%) had a relapse in the 6-month group compared with 8 (10%) in the 12-month group, with an absolute risk reduction of 0.29 [95% CI 0·16-0·40]. The mean time to first relapse was 23 months in the 12-month group, which is significantly longer than the mean of 18 months in the 6-month group (p<0.0001). There were 16 deaths in total, eight in each group. Ten (12%) of 81 patients in the 6-months group and 18 (22%) of 83 patients in the 12-months group had adverse effects, with none requiring treatment modification. Nausea and anorexia were the most common adverse events in both groups., Interpretation: Treatment of chronic pulmonary aspergillosis with 12 months of oral itraconazole was superior to 6 months of oral itraconazole in reducing relapses at 2 years. Itraconazole should be given for at least 12 months for treating chronic pulmonary aspergillosis., Funding: None., Translation: For the Hindi translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests, (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Various molecular underpinnings of lung cancer have been noted in Asian populations, especially with targetable oncogenic drivers such as EGFR mutations and ALK rearrangements, although they have been lesser described in South Asian/Indian patients., Methods: Tumour molecular testing results from non-small cell lung cancer (NSCLC) patients with a name of South Asian origin and diagnosed from 2005 to 2019 at the Stanford Cancer Center in the United States were retrospectively reviewed and compared to the results of molecular testing from PGIMER in Chandigarh, India, from the patients diagnosed from 2011 to 2019., Results: We identified 72 patients of South Asian (largely Indian) origin, of whom 64 patients (51% female) had mutational testing at Stanford. Of the tested patients, 33% of cases harboured either an EGFR exon 19 deletion or exon 21 L858R mutation, and 12.5% had ALK rearrangements. At PGIMER, a larger sample of 1,264 patients was identified (33% female), with 22.5% of patients having two main EGFR activating mutations, and 9.5% harbouring an ALK rearrangement., Conclusions: South Asian, largely Indian, patients with NSCLC appear to have a higher chance of harbouring EGFR mutations and ALK translocation as compared to Caucasians. The percentage of South Asian patients with these molecular abnormalities was largely similar in two different geographical locations. These findings corroborate prior single-institution findings and emphasise the importance of molecular testing., Competing Interests: None

Competing Interests: None

Background: SARSCoV-2, a coronavirus that causes COVID-19, is spreading rapidly. By the middle of August-2021, it has affected over 3 million confirmed cases in India. The main aim of this study was to examine the clinical profile of COVID-19 patients and their length of stay during treatment in a hospital., Materials and Methods: It was a hospital-based retrospective study conducted by using a total enumeration technique in July-August 2021 at Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER) in India. The present study was conducted on 72 COVID-19 patients who took treatment in 4C and 5C wards. Structured questionnaires were used to collect data, which included bio-demographic factors and questions about their treatment and length of stay., Results: The majority of the 72 COVID-19 positive patients were men (62%), belonged to the age group of 41-60 years (35%), had SpO 2 levels ranging from 91%-95% (45%), and received room air O 2 therapy (63%) during their treatment in the hospital. Female patients had a longer length of stay (7.33 days), patients under the age of 20 years had the longest hospital stay (11.5 days), patients with SpO 2 less than 70% had the longest hospital stay (8 days), and patients who received oxygen using a non-rebreathing mask had the longest hospital stay (11 days)., Conclusion: To avoid panic situations, regular admission and discharge of patients was essential due to the considerable increase in cases during the second wave. Patient length of stay was reduced as a consequence of collaboration and cooperation among all physicians, residents, staff nurses, and paramedics, with the goal of discharging the patient after a room air trial and follow up if needed., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background: Venous thromboembolism (VTE) in cancer remains underdiagnosed. This prospective study aimed to evaluate the feasibility of screening for VTE in lung cancer (LC) patients. We assess the incidence of VTE, its risk factors, and effects on overall survival (OS)., Methods: Consecutive treatment-naive LC patients were screened for deep venous thrombosis (DVT) with compression ultrasonography and pulmonary thromboembolism (PTE) with computed tomography pulmonary angiography (CTPA) at diagnosis and after 3 months of treatment. The incidence rate of VTE (DVT and/or PTE) was calculated. Risk factors associated with VTE were assessed using logistic regression analysis. All participants were followed-up to 1 year after enrollment. OS was compared in LC subjects with and without VTE, using the Cox proportional hazard analysis., Results: Around 301 subjects with LC (stages IIIB-IV accounted for 83.1%) were enrolled, of which 16 had VTE (5.3%). The incidence rate of VTE was 90 per 1000 person-years (PY). PTE was asymptomatic in 27.3% of cases while all DVT episodes were symptomatic. The incidence rate of asymptomatic PTE identified during the screening was 17 per 1000 PY. The median duration from LC diagnosis to the VTE event was 96.5 days. Median OS was significantly less in VTE patients [161 versus 311 days; P = 0.007] and death was attributable to VTE in 50%. After adjusting for covariates, VTE (hazard ratio [HR] = 2.1), smoking (HR = 1.7), and Eastern cooperative oncology group performance status ≥2 (HR = 1.6) were independently associated with poor OS in LC., Conclusions: VTE occurs in approximately 1 in 20 newly-diagnosed patients with LC and is associated with decreased OS. Screening for PTE may be considered even in resource-limited settings., Competing Interests: None

Background: The modified International Society for Human and Animal Mycology (ISHAM) allergic bronchopulmonary aspergillosis (ABPA) working group (AWG) criteria lists up to five components for diagnosing ABPA in asthmatics. Whether eliminating specific components of the existing criteria would have the same diagnostic utility as the original remains unknown., Objective: To evaluate the performance of several simplified criteria for diagnosing ABPA., Methods: We compared the performance of seven new criteria (after excluding or modifying one or more of the components of the ISHAM-AWG criteria) with the modified ISHAM-AWG criteria in asthmatic subjects using latent class analysis (LCA). We also tested the performance of the newer criteria using accuracy measures against a multidisciplinary team (MDT) diagnosis of ABPA. We considered the diagnostic accuracy of the newer criteria to be acceptable if the correct classification and false-negative rates were >95% and <5%, respectively, on an MDT evaluation., Results: We analyzed data from 543 asthmatic subjects (58.8% women; mean age, 36.8 years). Using LCA, the sensitivity of the A.fumigatus -specific IgE-based criteria ranged from 92-99%, while the specificity varied between 92% and 100%. The MDT diagnosed ABPA in 106 (19.5%) subjects. Using MDT as the reference standard, the correct classification and false-negative rates were >95% for three of the seven and <5% for four of the seven newer criteria., Conclusions: We found several of the newly developed criteria to perform, like the modified ISHAM-AWG criteria, for diagnosing ABPA complicating asthma. A prospective study in current clinical algorithms is required for validating our observations., Competing Interests: RA has received grant support from Cipla, India on research in ABPA PS. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Agarwal, Saxena, Muthu, Sehgal, Dhooria, Prasad, Aggarwal and Chakrabarti.)

Purpose of Review: Asthma and chronic obstructive pulmonary disease (COPD) are widely prevalent disorders, and important contributors to morbidity and mortality, in both developing and developed countries. It is conjectured that these obstructive lung diseases may have had more deleterious effects in developing nations during the 2019 coronavirus disease (COVID-19) pandemic. We provide an evidence-based perspective on the relationship between asthma/COPD prevalence and COVID-19 burden, and the impact of comorbid asthma/COPD on selected COVID-19 outcomes and healthcare utilization, with special reference to developing countries., Recent Findings: Developing countries with higher COPD (but not asthma) prevalence appear to have higher COVID-19 related mortality. Patients with asthma (but not COPD) in developing countries may be less likely to acquire COVID-19. Published literature suggests that the overall impact of comorbid asthma or COPD on adverse COVID-19 outcomes may be broadly similar between developed and developing nations., Summary: There is paucity of information on interaction between asthma/COPD and COVID-19 in developing countries. Limited data suggest minor differences between developed and developing nations. In view of inadequacies in healthcare preparedness and delivery in several developing countries, there is a need to generate quality evidence to assess impact of obstructive lung diseases and COVID-19 on each other., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Allergic bronchopulmonary aspergillosis (ABPA) is a complex allergic disorder caused by immune reactions against Aspergillus fumigatus. ABPA most commonly complicates the course of patients with poorly controlled asthma. Patients commonly present with uncontrolled asthma, fleeting pulmonary opacities, and bronchiectasis. Pathogenetically, ABPA is characterized by the persistence of A. fumigatus in the airways and an exaggerated type-2 immune response. The interest in ABPA stems from the fact that bronchiectasis in ABPA can be prevented if the disorder is diagnosed timely and treated appropriately. Herein, we summarize the current concepts in the epidemiology, pathogenesis, diagnosis, and treatment of ABPA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN, Agarwal R. Corticosteroids for Non-severe COVID-19: Primum Non Nocere. Indian J Crit Care Med 2022;26(3):403-404., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: The prevalence and outcomes of allergic bronchopulmonary aspergillosis (ABPA) in the elderly remain unknown., Methods: We reviewed our database to identify the proportion of subjects diagnosed with ABPA at ≥60 years of age (ABPA-elderly). We compared the clinical features, treatment and outcomes of ABPA-elderly versus the non-elderly (ABPA diagnosed at <60 years of age)., Results: Between 2007 and 2019, we encountered 810 ABPA subjects with a mean age of 34.9 years (49.4% women). Of these, 43 (5.3%) were aged ≥60 years (ABPA-elderly). There was a trend towards lower median (interquartile range [IQR]) serum total IgE (4900 [2659-10000] vs. 7156 [23360-11963] IU/mL; P = .06) and Aspergillus fumigatus-specific IgE (12.3 [4.8-29.6] vs. 22.4 [7.7-41.5] kUA/L; P = .06) in the elderly than the non-elderly. Eosinophil counts were similar in the two groups. The median [IQR] number of segments involved by bronchiectasis (5 [2-9] vs. 7 [4-11]) was significantly lower in the ABPA-elderly (P = .001). The proportion of subjects experiencing ABPA exacerbations was significantly (P = .047) lower in the elderly (25.6%) vs. the non-elderly (40.8%). There was also a tendency towards a lower mean number of exacerbations in the elderly (155 vs. 208 exacerbation per 1000 person-years) than the non-elderly (P = .09). There was also a trend towards longer mean time to first exacerbation in the ABPA-elderly than the non-elderly (1612 vs. 1159 days)., Conclusion: ABPA was uncommon in the elderly. The bronchiectasis is less extensive with a trend towards lower immunological severity and fewer exacerbations in the elderly than the non-elderly subjects with ABPA., (© 2021 Wiley-VCH GmbH.)

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by the accumulation of surfactant in the alveolar spaces resulting in hypoxemic respiratory failure. Whole lung lavage (WLL), the preferred treatment for PAP, physically removes the lipoproteinaceous material from the alveolar spaces. Since its initial description in 1963, the WLL procedure has undergone various modifications. However, the procedure has not been standardized yet. After securing a double lumen endotracheal tube, we perform WLL under general anesthesia. One lung is ventilated, while the other is lavaged using one-liter aliquots of pre-warmed saline. We use gravity-assisted drainage of the lavaged lung after each cycle till the milky white and opaque fluid becomes clear (usually 15-20 cycles). Herein, we describe the step-by-step procedure, precautions, and monitoring of WLL. We also provide videos demonstrating one-lung ventilation and bronchoscopic confirmation of lung isolation., Competing Interests: Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

Background: Whether dysregulated iron metabolism is associated with COVID-19-associated mucormycosis (CAM) remains unknown. Herein, we compare the serum iron indices in COVID-19 subjects with and without mucormycosis., Methods: We conducted a case-control study enrolling COVID-19 participants with and without mucormycosis. We compared the baseline serum iron indices (iron, ferritin, total iron-binding capacity [TIBC], unsaturated iron-binding capacity and percentage transferrin saturation) between CAM cases and COVID-19 controls. Additionally, we performed a multivariate logistic regression analysis to assess whether any iron indices are associated with CAM., Results: We enrolled 28 CAM cases (mean age 53.6 years old; 78.6% men) and 26 controls (mean age 57.2 years old; 73.1% men). Rhino-orbital (±cerebral) mucormycosis (85.7%) was the most clinical presentation. Diabetes mellitus was more frequent in the cases than controls (75% vs. 42.3%; p = .015). Hypoxaemia during COVID-19 illness was more common in controls than cases. The mean serum iron values (33 vs. 45 μg/dl, p = .03) and TIBC (166.6 vs. 201.6 μg/dl, p = .003) were significantly lower in CAM cases than controls. On multivariate analysis, we found a lower TIBC (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.95-0.99) and diabetes mellitus (OR 5.23; 95% CI, 1.21-22.68) to be independently associated with CAM after adjusting for serum iron, ferritin and glucocorticoid therapy. The case fatality rate of CAM was 73.9%. The iron indices were not significantly different between CAM survivors and non-survivors., Conclusions: The CAM is associated with lower TIBC levels than COVID-19 subjects without mucormycosis, suggesting dysregulated iron metabolism in its pathogenesis. Further studies are required to confirm our preliminary observations., (© 2021 Wiley-VCH GmbH.)

Case Presentation: A 37-year-old man presented with breathlessness and wheeze of 3 weeks' duration. There was no chest pain, cough, palpitation, pedal edema, or fever. For the past 12 years, he had been experiencing episodic breathlessness and wheeze, which improved with inhaled salbutamol. He also had symptoms of nasal obstruction, nasal discharge, and sneezing. There was no history of smoking, substance abuse, or the use of any over-the-counter medication. The current episode of bronchial asthma exacerbation was managed with bronchodilators and systemic glucocorticoids. Despite symptomatic relief and clinical improvement, his oxygen saturation remained at 75% to 80%, and he was referred to our facility for further evaluation., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: We conducted this systematic review to evaluate whether asthma increases the risk of severe disease and adverse outcomes among subjects with COVID-19., Methods: We queried the PubMed and Embase databases for studies indexed through December 2020. We included studies providing data on severe disease, hospitalization, ICU care, need for mechanical ventilation, or mortality among subjects with COVID-19 with and without asthma. We calculated the relative risk for each reported outcome of interest and used random effects modeling to summarize the data., Results: We retrieved 1,832 citations, and included 90 studies, in our review. Most publications reported data retrieved from electronic records of retrospective subject cohorts. Only 25 studies were judged to be of high quality. Subjects with asthma and COVID-19 had a marginally higher risk of hospitalization (summary relative risk 1.13, 95% CI 1.03-1.24) but not for severe disease (summary relative risk 1.17, 95% CI 0.62-2.20), ICU admission (summary relative risk 1.13, 95% CI 0.96-1.32), mechanical ventilation (summary relative risk 1.05, 95% CI 0.85-1.29), or mortality (summary relative risk 0.92, 95% CI 0.82-1.04) as compared to subjects with COVID-19 without asthma., Conclusions: Comorbid asthma increases risk of COVID-19-related hospitalization but not severe disease or other adverse outcomes in subjects with COVID-19., Competing Interests: The authors have no conflicts to disclose., (Copyright © 2021 by Daedalus Enterprises.)

Background: Data on the prevalence of programmed death-ligand 1 (PD-L1) expression and tumor-infiltrating lymphocytes (TILs) in non-small cell lung cancer (NSCLC) and their clinical significance in Indian patients are limited., Methods: Newly diagnosed NSCLC cases (adenocarcinoma or squamous cell carcinoma [SqCC] histology) were included in the present study. The TILs were evaluated based on morphology on hematoxylin and eosin-stained slides. PD-L1 expression in tumors was assessed using immunohistochemistry with rabbit monoclonal antibody (SP263) on the Ventana automated immunostainer. Tumors with PD-L1 expression > 50% on tumor cells were considered PD-L1-positive. Tumors in which TILs occupy > 25% of stroma were considered to have high TILs. The association of PD-L1 expression and TILs with various clinical parameters including overall survival (OS) was investigated., Results: The present study included 128 cases of NSCLC (67 adenocarcinoma, 61 SqCC). PD-L1 positivity was observed in 17.2% of the patients with NSCLC. Baseline characteristics of PD-L1-positive subjects were similar to PD-L1-negative subjects except for a higher prevalence of liver metastasis (18.2% vs. 2.8%; p = .018) and a higher probability of diagnosis from extrapulmonary biopsies. High TILs were observed in 26.6% of the subjects. However, PD-L1 expression and high TIL did not affect OS., Conclusions: PD-L1 positivity and high TILs were observed in 20% and 25% of the patients with NSCLC, respectively, however, neither were predictors of survival in SqCC.

Objective: The proportion of COVID-19 patients having active pulmonary tuberculosis, and its impact on COVID-19 related patient outcomes, is not clear. We conducted this systematic review to evaluate the proportion of patients with active pulmonary tuberculosis among COVID-19 patients, and to assess if comorbid pulmonary tuberculosis worsens clinical outcomes in these patients., Methods: We queried the PubMed and Embase databases for studies providing data on (a) proportion of COVID-19 patients with active pulmonary tuberculosis or (b) severe disease, hospitalization, or mortality among COVID-19 patients with and without active pulmonary tuberculosis. We calculated the proportion of tuberculosis patients, and the relative risk (RR) for each reported outcome of interest. We used random-effects models to summarize our data., Results: We retrieved 3,375 citations, and included 43 studies, in our review. The pooled estimate for proportion of active pulmonary tuberculosis was 1.07% (95% CI 0.81%-1.36%). COVID-19 patients with tuberculosis had a higher risk of mortality (summary RR 1.93, 95% CI 1.56-2.39, from 17 studies) and for severe COVID-19 disease (summary RR 1.46, 95% CI 1.05-2.02, from 20 studies), but not for hospitalization (summary RR 1.86, 95% CI 0.91-3.81, from four studies), as compared to COVID-19 patients without tuberculosis., Conclusion: Active pulmonary tuberculosis is relatively common among COVID-19 patients and increases the risk of severe COVID-19 and COVID-19-related mortality., Competing Interests: The authors have declared that no competing interests exist.

Background: Mycobacterium w (Mw), an immunomodulator, has been shown to resolve early organ failure in severe sepsis., Research Question: Does Mw improve survival in patients with severe presumed gram-negative sepsis?, Study Design and Methods: This was a randomized, double-blind, placebo-controlled, parallel-group study conducted in ICUs of five tertiary care centers in India. We included consecutive patients (age ≥ 18 years) with presumed gram-negative sepsis in the study within 48 h of the first organ dysfunction. Patients in the treatment arm received 0.3 mL/d of Mw intradermally for 3 consecutive days, whereas the control arm received matching placebo. The primary outcome was 28-day all-cause mortality. The secondary outcomes were ventilator-free days, days receiving vasopressor therapy, ICU and hospital length of stay, nosocomial infection rate, antibiotic use duration, and delta Sequential Organ Failure Assessment (SOFA) score., Results: We included 202 patients with severe sepsis (101 Mw, 101 placebo). The use of Mw significantly reduced the mortality (9/101 vs 20/101; estimate difference, 0.11 [95% CI, 0.01-0.21]; P = .04). We found no difference in ventilator-free days, days receiving vasopressor drugs, ICU length of stay, and the hospital length of stay. The time to mortality (median, 13 days vs 8.5 days) was significantly longer in the Mw than in the placebo arm. The delta SOFA score, rate of nosocomial infections, and antibiotic use duration were similar in the two arms. We found Mw to reduce significantly the odds (OR, 0.37 [95% CI, 0.15-0.9]) of mortality after adjusting for culture-positive sepsis, baseline SOFA score, age, and sex., Interpretation: The use of Mw was associated with a significant reduction in mortality in patients with severe presumed gram-negative sepsis. Further studies are required to confirm our findings., Trial Registry: ClinicalTrials.gov; No.: NCT02330432; URL: www.clinicaltrials.gov., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Whether a combination of glucocorticoid and antifungal triazole is superior to glucocorticoid alone in reducing exacerbations in patients with allergic bronchopulmonary aspergillosis (ABPA) remains unknown. We aimed to compare the efficacy and safety of prednisolone-itraconazole combination versus prednisolone monotherapy in ABPA., Methods: We randomised subjects with treatment-naïve acute-stage ABPA complicating asthma to receive either prednisolone alone (4 months) or a combination of prednisolone and itraconazole (4 and 6 months, respectively). The primary outcomes were exacerbation rates at 12 months and glucocorticoid-dependent ABPA within 24 months of initiating treatment. The key secondary outcomes were response rates, percentage decline in serum total IgE at 6 weeks, time to first ABPA exacerbation and treatment-emergent adverse events (TEAEs)., Results: We randomised 191 subjects to receive either prednisolone (n=94) or prednisolone-itraconazole combination (n=97). The 1-year exacerbation rate was 33% and 20.6% in the prednisolone monotherapy and prednisolone-itraconazole combination arms, respectively (p=0.054). None of the participants progressed to glucocorticoid-dependent ABPA. All of the subjects experienced a composite response at 6 weeks, along with a decline in serum total IgE (mean decline 47.6% versus 45.5%). The mean time to first ABPA exacerbation (417 days) was not different between the groups. None of the participants required modification of therapy due to TEAEs., Conclusions: There was a trend towards a decline in ABPA exacerbations at 1 year with the prednisolone-itraconazole combination versus prednisolone monotherapy. A three-arm trial comparing itraconazole and prednisolone monotherapies with their combination, preferably in a multicentric design, is required to define the best treatment strategy for acute-stage ABPA., Competing Interests: Conflict of interest: R. Agarwal has received grant support for conducting research in ABPA from Cipla Pharmaceuticals, Mumbai, India, outside the submitted work. Conflict of interest: V. Muthu has nothing to disclose. Conflict of interest: I.S. Sehgal has nothing to disclose. Conflict of interest: S. Dhooria has nothing to disclose. Conflict of interest: K.T. Prasad has nothing to disclose. Conflict of interest: M. Garg has nothing to disclose. Conflict of interest: A.N. Aggarwal has nothing to disclose. Conflict of interest: A. Chakrabarti has nothing to disclose., (Copyright ©The authors 2022. For reproduction rights and permissions contact permissions@ersnet.org.)

Background: Oral itraconazole and voriconazole are currently recommended in the initial management of chronic pulmonary aspergillosis (CPA). However, only a few studies have compared outcomes with different anti-fungal agents (AFAs) in treating CPA. Herein, we perform a network meta-analysis comparing the efficacy of different AFAs in CPA., Methods: We searched the PubMed and EmBase databases to identify studies (either randomised-controlled trials [RCTs] or observational) reporting treatment outcomes with AFAs in patients of CPA. The study quality was assessed using the Newcastle-Ottawa scale (NOS). We performed a network meta-analysis to compare the relative efficacy of different AFAs in treating CPA. The primary outcome was a favourable response to treatment with AFAs., Results: We found ten studies (718 patients) investigating different AFAs (oral AFAs [n = 5], intravenous AFAs [n = 5]) in the treatment of CPA. There were four RCTs and six observational studies. The studies using oral agents reported long-term outcomes (>12 weeks), while those with intravenous agents provided only short-term outcomes (<6 weeks). We found one study of posaconazole and none with isavuconazole for treating CPA. Amongst the oral agents, itraconazole was significantly better than supportive care and was ranked as the best oral AFA on network rank analysis. We found all intravenous AFAs to be equally effective. Intravenous echinocandins and voriconazole were ranked best for achieving a favourable treatment response., Conclusion: Oral itraconazole may be preferred over other azoles as the initial therapy for CPA. Amongst the intravenous agents, echinocandins and voriconazole may be preferred over amphotericin B. Randomised-controlled trials comparing different AFAs, especially the newer AFAs, are urgently needed., (© 2021 Wiley-VCH GmbH.)

Competing Interests: The authors declare no funding or conflicts of interest.

Background: Chemical pleurodesis is an important option for palliation in malignant pleural effusion (MPE)., Objectives: To evaluate the status of iodopovidone for pleurodesis in MPE., Methods: We performed a systematic review of PubMed and EMBASE databases to identify studies evaluating the role of iodopovidone for pleurodesis in MPE. We calculated the pooled success rate of iodopovidone pleurodesis from observational studies and the risk ratio (RR) of successful pleurodesis (compared to other agents) from randomized controlled trials (RCTs). We pooled the data using the random-effects model. We also assessed the safety of iodopovidone., Results: We included 26 studies (n = 1132, 15 observational, and 11 RCTs) in our review. The pooled success rate (95% confidence interval [CI]) from 15 observational studies (n = 648) was 90% (86-94). The efficacy rate of iodopovidone was similar with either tube thoracostomy or thoracoscopy. Eleven (n = 484) RCTs compared the efficacy of iodopovidone with other agents (especially bleomycin and talc). We found a similar success rate of iodopovidone compared to other agents with a pooled RR (95% CI) of 0.99 (0.91-1.08). The most frequent adverse event was chest pain. No hypo or hyperthyroidism, or visual disturbance was encountered in any study. There were no deaths attributed to iodopovidone use., Conclusions: Iodopovidone is a safe and effective agent for pleurodesis in the management of MPE. Further confirmation is required since the available evidence is limited by the low quality and small sample size of the included studies.

Objective: We compared diagnostic accuracy of pleural fluid adenosine deaminase (ADA) and interferon-gamma (IFN-γ) in diagnosing tuberculous pleural effusion (TPE) through systematic review and comparative meta-analysis., Methods: We queried PubMed and Embase databases to identify studies providing paired data for sensitivity and specificity of both pleural fluid ADA and IFN-γ for diagnosing TPE. We used hierarchical summary receiver operating characteristic (HSROC) plots and HSROC meta-regression to model individual and comparative diagnostic performance of the two tests., Results: We retrieved 376 citations and included 45 datasets from 44 publications (4974 patients) in our review. Summary estimates for sensitivity and specificity for ADA were 0.88 (95% CI 0.85-0.91) and 0.91 (95% CI 0.89-0.92), while for IFN-γ they were 0.91 (95% CI 0.89-0.94) and 0.96 (95% CI 0.94-0.97), respectively. HSROC plots showed consistently greater diagnostic accuracy for IFN-γ over ADA across the entire range of observations. HSROC meta-regression using test-type as covariate yielded a relative diagnostic odds ratio of 2.22 (95% CI 1.68-2.94) in favour of IFN-γ, along with better summary sensitivity and specificity figures. No prespecified subgroup variable significantly influenced the summary diagnostic accuracy estimates., Conclusion: Pleural fluid IFN-γ estimation has better diagnostic accuracy than ADA estimation for diagnosis of TPE., Competing Interests: The authors have declared that no competing interests exist.

Background: There are sparse data on the role of flexible bronchoscopy (FB) in diagnosing invasive mould infections (IMIs)., Objective: To investigate the safety and usefulness of FB in IMI. We evaluate the factors associated with a successful diagnosis of IMI using FB. Further, we compare subjects of invasive pulmonary aspergillosis (IPA) with pulmonary mucormycosis (PM)., Methods: We retrospectively reviewed the clinical features, imaging data, bronchoscopy, microbiology and pathology details of subjects who underwent FB for suspected IMI. We categorised FB as diagnostic if it contributed to the diagnosis of IMI. We performed a multivariate analysis to identify the factors associated with a diagnostic bronchoscopy., Results: Of the 3521 FB performed over 18 months, 132 (3.7%) were done for suspected IMIs. We included 107 subjects for the final analysis. The risk factors for IMI included renal transplantation (29.0%), diabetes (27.1%), haematological malignancy (10.3%) and others. We found bronchoscopic abnormalities in 33 (30.8%) subjects, and these were more frequent in those with confirmed PM (67%) than IPA (27%). IMI was confirmed in 79 (14 proven, 48 probable and 17 possible) subjects. FB was diagnostic in 71%. We experienced major complications in three cases (2.7%), including one death. On multivariate analysis, the visualisation of endobronchial abnormalities during FB (OR [95%, CI], 8.5 [1.4-50.4]) was the only factor associated with a diagnostic FB after adjusting for age and various risk factors., Conclusions: Flexible bronchoscopy is a useful and safe procedure in diagnosing IMIs. The presence of endobronchial abnormalities predicts a successful diagnostic yield on FB., (© 2021 Wiley-VCH GmbH.)