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Esophageal cancer is the most common cause of extrapulmonary malignant central airway obstruction (MCAO). MCAO is usually managed by a multidisciplinary approach involving tumor debulking, stent placement, and palliative radiotherapy. MCAO is a challenge in itself; here, it becomes even more challenging as it was accompanied by grade 3 oral submucous fibrosis, nasal synechiae, and multiple enlarged cervical nodes causing excessive compression of the trachea along with acute hypercapnic respiratory failure. Herein, a 65-year-old woman with multiple challenges, where death was imminent, managed with a collaborative approach involving awake nasal intubation in the sitting position and placement of a stent via a flexible bronchoscope, as rigid bronchoscopy was not possible in view of limited mouth opening. Overcoming these challenges led to completing the procedure successfully and palliating the symptoms.

Introduction: Machine learning algorithms have been used to develop prediction models in various infectious and non-infectious settings including interpretation of images in predicting the outcome of diseases. We demonstrate the application of one such simple automated machine learning algorithm to a dataset obtained about COVID-19 spread in South Korea to better understand the disease dynamics. Material and methods: Data from 20th January 2020 (when the first case of COVID-19 was detected in South Korea) to 4th March 2020 was accessed from Korea’s centre for disease control (KCDC). A future time-series of specified length (taken as 7 days in our study) starting from 5th March 2020 to 11th March 2020 was generated and fed to the model to generate predictions with upper and lower trend bounds of 95% confidence intervals. The model was assessed for its ability to reliably forecast using mean absolute percentage error (MAPE) as the metric. Results: As on 4th March 2020, 145,541 patients were tested for COVID-19 (in 45 days) in South Korea of which 5166 patients tested positive. The predicted values approximated well with the actual numbers. The difference between predicted and observed values ranged from 4.08% to 12.77% . On average, our predictions differed from actual values by 7.42% (MAPE) over the same period. Conclusion: Open source and automated machine learning tools like Prophet can be applied and are effective in the context of COVID-19 for forecasting spread in naïve communities. It may help countries to efficiently allocate healthcare resources to contain this pandemic.

The majority of lung cancers are diagnosed at an advanced stage; the reasons for which are variable and unclear.Lung cancer patients were evaluated prospectively to quantify various timelines and establish reasons for delays. Timelines were defined as time intervals between symptom onset, first physician visit, first specialist visit, date of diagnosis and treatment.A total 410 patients were included, majority having advanced disease. The median period for a first visit to a physician was 30 days (interquartile range [IQR] 20-90), 50 days (IQR 20-110) for referral to our centre, 23 days (IQR 14-33) to reach diagnosis, and 24 days (IQR 14.5-34) to initiate treatment. Administration ofanti-tuberculosis treatment further delayed referral to specialist centre. Treatment delays were related to performance status, disease stage and treatment type. On multivariate analysis, education and histology affected diagnosis delay and treatment delay. Treatment delay was less in those who received targeted therapy compared to chemotherapy. Various time delays did not affect the overall survival.Poor education status and inappropriate anti-tubercular treatment were primary factors associated with longer diagnostic delays. Creating disease awareness and high clinical suspicion are essential to overcome these lacunae in lung cancer care.

In adults, central airway obstruction (CAO) can occur due to several benign and malignant etiologies either due to an endobronchial growth or extrinsic compression [...]

As no definitive therapy or vaccine is yet available for COVID-19, in a desperate attempt repurposed drugs are being explored as an option. A drug repurposing study identified Ciclesonide as a potential candidate. We reviewed the available evidence and clinical trials on the use of Ciclesonide in COVID-19. At present the evidence is limited to a report of three cases. However, five clinical trials are underway, and their results will help in elucidating the role of Ciclesonide in COVID-19.

Background Chest pain is one of the most common symptoms with which a patient presents to a doctor. Differentials include, but are not limited to, cardiac pulmonary, gastrointestinal, psychosomatic and musculoskeletal causes. In our case, ultrasound of the chest wall paved the way for the diagnosis of multiple myeloma, which occultly presented with chronic chest pain. Case summary Here we report a case of 50-year-old man with chronic chest pain without anemia or renal failure who was diagnosed with multiple myeloma, despite negative bence jones protein and M band electrophoresis. An ultrasound of the chest wall showed cortical irregularities along with a hypoechoic mass in the sternum and left 5th rib, which helped us in clinching the diagnosis. Conclusion Ultrasound of bone can often aid in reaching a diagnosis indirectly if not directly.

Abdominal tuberculosis is an important yet ignored entity in the spectrum of tuberculosis which has been dominated by pulmonary tuberculosis. Diagnosis and treatment are often delayed due to nonspecific symptoms. In this study, we aimed to highlight the clinical features, diagnostic methods and outcomes of abdominal tuberculosis.A prospective study was conducted in tertiary referral centre where all patients referred to drug distribution centres (DOTS centre) for abdominal tuberculosis were identified. Their demographic clinical and radiological profile was evaluated. These patients were followed-up for their treatment course for complications and outcomes.A total of 140 patients who were labelled abdominal tuberculosis over a period of 2 years were reviewed at tuberculosis drug distribution centre (DOTS). Mean age of study population was 35.42 ± 12.53 years and majority of the population were males, 58.6% (82). The most common presenting symptom was abdominal pain which was seen in 82.8% (Abdominal tuberculosis usually presents with nonspecific complaints which require high index of suspicion. Most patients require only medical therapy which has good results.

Critical central airway obstruction has always been a dreaded complication to which interventional pulmonologist commonly encounters. There have been various modalities which are used for the management and palliation, which includes mechanical coring, laser, cryoextraction, electrocautery and airway stenting. Rigid bronchoscopy with or without jet ventilation has been corner stone of therapeutics and palliation of central airway obstruction. There are only a few conditions where it is not possible to use rigid bronchoscopy. Here we report a case of metastatic tracheal tumour which presented with critical airway obstruction in a patient who had atlantoaxial instability (AAI) due to rheumatoid arthritis. Here we used endobronchial ultrasound scope (EBUS) via esophageal route, i.e. EUS-B guided approach for sampling of the tracheal tumour, and intratumoral chemotherapy was instilled in multiple sessions, which resulted in shrinking of tumour, thus relieving the critical airway obstruction. This is the first report of using EUS-B approach for intratumoral chemotherapy for tracheal tumors. Bronchoscopic intratumoral chemotherapy therapy (BITC) in tracheal tumors is also one of the options but has not been explored much and there has been a dearth of literature for it.

Aim: To study the serum levels of fibrinogen in patients with obstructive sleep apnea (OSA) and its correlation with apnea hypopnea index (AHI), oxygen desaturation index (ODI), minimal oxygen saturation & arousal index. Methods: It was a case control study in which 23 cases of OSA and 23 controls were enrolled. Morning fasting serum fibrinogen and d-dimer was measured in cases of OSA and controls. Those with liver disease, hypertension, diabetes mellitus, coronary artery disease, COPD, alcoholics and smokers were excluded from the study. Results: Serum fibrinogen levels among OSA patients (268.47 ± 53.11 mg/dl) were elevated as compared to their levels in controls (221.52 ± 65.84 mg/dl) (p Conclusions: The observation of elevated fibrinogen levels with the increasing severity of OSA and hypoxemic events makes OSA an independent risk factor for cardiovascular disorders.

Introduction: Pulmonary involvement in form of interstitial lung disease (ILD) occurs frequently in patients with connective tissue diseases (CTD). Hence, a high index of suspicion for respiratory disease among patients with CTDs is necessary if intervention is to impact the high morbidity and reduce premature death. Aims and Objectives: To study the symptoms, signs and radiological pattern of pulmonary diseases related to CTD. Material and Methods: Prospective, observational study. Diagnosed cases of CTD9s presenting to pulmonary department with respiratory symptoms and cases of ILD who were found to have CTD during evaluation were recruited in the study. Clinical profile was noted and high resolution computed tomography of chest, spirometry and 2D-echocardiography were performed. Results: A total of 100 patients were recruited. 78% patients were female and majority belonged to age group 41-50 years. 90% cases presented with chest symptoms and were found to have some form of CTD. Chief respiratory complaints were cough and dyspnea while joint pain was the commonest rheumatological symptom. Clubbing was present in 29% cases. Rheumatoid arthritis (RA) was the most common CTD followed by systemic sclerosis. Restrictive ventilatory defect was present in 58% cases on spirometry. Pulmonary hypertension was present in 40% patients and was most commonly seen in patients with MCTD. Chest X ray was normal in 47% cases. NSIP pattern was the most common pattern on HRCT found in 42% patients while UIP pattern was predominant pattern in patients with RA. Conclusion: CTD should be suspected in all patients with symptoms and signs of ILD particularly in middle aged female patients.

Rationale: Magnetic phrenic nerve stimulation is the gold standard to assess diaphragm function by measuring transdiaphragmatic pressure (Pdi) using esophageal and gastric balloon. Ultrasound has been used to accurately assess diaphragm function. We measured Pdi by magnetic phrenic nerve stimulation and tried to correlate it with diaphragm dynamics along with spirometry in COPD patients. Methods: Study Design: Cross sectional ; Site of study: PMSD, AIIMS, New Delhi;Study population: 60 Stable moderate/severe COPD;Duration : July 2017 to December 2018 Results: Of the 60 patients 26 had moderate and 34 patients had severe COPD. Mean FEV1 ,FVC ,TLC ,RV/TLC were 1.44 L(56.8% predicted), 2.57 L(81.3%), 6.43L (121%) and 63.42% respectively. On diaphragmatic ultrasound mean TD at FRC(mm), TD at RV(mm), TD at TLC(mm), tidal excursion (cm) and forced excursion (cm) was 1.60, 1.56, 2.32, 2.17, 3.22 respectively. Mean twitch Pdi was 22 cm H20 (max 35 and min 15 cm H2O),mean sniff Pdi was 64.9 cm H2O (max 75 and min 35 cm H20). Sniff Pdi correlated with real time excursion(REX),TDRV, tidal excursion and twitch Pdi correlated with real time excursion and FVC. Sniff Pdi was = 31+15.11(REX) with r2 value of 0.62 and twitch Pdi was = 11.84+4.54( REX) with r2 value of 0.48.Using multivariate regression analysis sniff Pdi was calculated as,10.3+13.11(TD RV) +6.19(Tidal excursion)+10.20(REX) with r2 value of 0.76 and twitch pdi was calculated as, 3.56 +3.98(FVC)+3.73(REX) with r2 value of 0.66. Conclusion: Twitch Pdi during magnetic stimulation and sniff Pdi can be calculated using ultrasound and spirometry parameters.

Iidiopathic pulmonary fibrosis (IPF) diagnosis and treatment during this COVID-19 pandemic have been affected. COVID-19 has not only impacted the prognosis of these patients but also the approach to these patients. Pulmonary function tests (PFT) and lung biopsies are less encouraged now. Traditional antifibrotics used in IPF should be encouraged irrespective of patient lung function and in those with non-definite usual interstitial pneumonia in high resolution computed tomography.

Countries all over the world writhing under the wrath of coronavirus face not only the challenge of protecting their population but the tougher challenge of protecting their healthcare workers (HCWs) dealing with the patient population. This pandemic has put unprecedented pressure on global healthcare systems, with personal protective equipment (PPE) being the most notable one. Apart from the challenge of procurement of PPE, the major challenge is rationalizing the use of PPE in this war against corona virus disease 19 (COVID19). Using PPE comes with its own set of problems such as extreme exhaustion, rashes, inability to consume food, or use washroom which can result in clouding of judgment and breach of infection barrier. Making PPE user-friendly and limiting the interaction of HCW with COVID19 patients coupled with the use of robotics, telemedicine, and other innovations is the need of the hour. How to cite this article Chawla G, Abrol N, Kakkar K. Personal Protective Equipment: A Pandora’s Box. Indian J Crit Care Med 2020;24(5):371–372.

As no definitive therapy or vaccine is yet available for COVID-19, in a desperate attempt repurposed drugs are being explored as an option. A drug repurposing study identified Ciclesonide as a potential candidate. We reviewed the available evidence and clinical trials on the use of Ciclesonide in COVID-19. At present the evidence is limited to a report of three cases. However, five clinical trials are underway, and their results will help in elucidating the role of Ciclesonide in COVID-19.

COVID-19 (COrona VIrus Diagnosed in 2019) is the most important health crisis of the present generation [...]

Coronavirus disease 2019, i.e. COVID-19, started as an outbreak in a district of China and has engulfed the world in a matter of 3 months. It is posing a serious health and economic challenge worldwide. However, case fatality rates (CFRs) have varied amongst various countries ranging from 0 to 8.91%. We have evaluated the effect of selected socio-economic and health indicators to explain this variation in CFR. Countries reporting a minimum of 50 cases as on 14th March 2020, were selected for this analysis. Data about the socio-economic indicators of each country was accessed from the World bank database and data about the health indicators were accessed from the World Health Organisation (WHO) database. Various socioeconomic indicators and health indicators were selected for this analysis. After selecting from univariate analysis, the indicators with the maximum correlation were used to build a model using multiple variable linear regression with a forward selection of variables and using adjusted R-squared score as the metric. We found univariate regression results were significant for GDP (Gross Domestic Product) per capita, POD 30/70 (Probability Of Dying Between Age 30 And Exact Age 70 From Any of Cardiovascular Disease, Cancer, Diabetes or Chronic Respiratory Disease), HCI (Human Capital Index), GNI(Gross National Income) per capita, life expectancy, medical doctors per 10000 population, as these parameters negatively corelated with CFR (rho = -0.48 to -0.38 , p

We aimed to evaluate the effects of stage-matched repeated individual behavioural counselling (RIBCS) on the basis of the transtheoretical model (TTM) as an intervention to reduce and stop smoking. This study was conducted over a period of one year where all smokers presenting to a chest clinic in a tertiary centre were enrolled, each was classified on the basis of stage of readiness to change and underwent repeated counselling for a period of six months and each session was preceded and succeeded with filling of Fagerstorm test for nicotine dependence. Over the period of a year, 207 patients participated in this study, the mean age was 50.74±14.74 years; mean duration of tobacco use was 29.43±14.72 years; 64.3% were illiterate, 11.6% primary education, 14.1% were matric and while 10.1% were graduate. About 73% of smokers reported high level of nicotine dependence (FTND score >5/10). In the present study mean dependence score was 6.0±1.96; 44 (21.3%) were in pre-contemplation stage, 93 (44.9%) were in contemplation, 57 (27.5%) were in preparation and 13 (6.3%) were in action. The point prevalence excellence rate in follow up-I was 15%, follow up-II was 35.3% and follow up-III was 61.9% which was statistically significant. When we took both abstinence and reduction in smoking behaviour as one, p-value was

Lung cancer is posing an ever-increasing medical and social problem due to its increasing morbidity and mortality. Here we report a case of a young male who was being treated as tubercular pleural effusion but was ultimately diagnosed with non-small cell carcinoma. While considering the diagnosis of pleural effusion, in the context of country endemic for tuberculosis like India, it is not surprising that many clinicians rather prefer to consider pulmonary tuberculosis as the first differential, while keeping diagnosis of malignancy as the least likely differential diagnosis in the young patient.

Foreign body aspiration is not very common in adults, clinically, patients either present with acute respiratory failure which require immediate intervention or with recent onset of symptoms, like wheezing, breathlessness, coughing, and expectoration.

Benign mediastinal teratomas often discovered while patients are still asymptomatic. Almost all arise in the anterosuperior mediastinal compartment. Most symptoms result from compression of adjacent structures. We report a case of a large teratoma arising from the anterior mediastinum that presented a confusing clinical picture of loculated pleural effusion which was successfully diagnosed and treated by surgical excision.

Countries all over the world writhing under the wrath of coronavirus face not only the challenge of protecting their population but the tougher challenge of protecting their healthcare workers (HCWs) dealing with the patient population. This pandemic has put unprecedented pressure on global healthcare systems, with personal protective equipment (PPE) being the most notable one. Apart from the challenge of procurement of PPE, the major challenge is rationalizing the use of PPE in this war against corona virus disease 19 (COVID19). Using PPE comes with its own set of problems such as extreme exhaustion, rashes, inability to consume food, or use washroom which can result in clouding of judgment and breach of infection barrier. Making PPE user-friendly and limiting the interaction of HCW with COVID19 patients coupled with the use of robotics, telemedicine, and other innovations is the need of the hour. How to cite this article Chawla G, Abrol N, Kakkar K. Personal Protective Equipment: A Pandora's Box. Indian J Crit Care Med 2020;24(5):371-372.

A 59-year-old married male, a known case of line probe assay-confirmed multidrug-resistant pulmonary tuberculosis was treated with kanamycin, levofloxacin, ethionamide, ethambutol, pyrazinamide and cycloserine for seven months [...]

Background: Since time immemorial tuberculosis (TB) has been and continues to be one of the most significant infections causing human disease. In tropical countries, TB remains a leading cause of death. Human immunodeficiency virus (HIV) epidemic continues to fuel this global TB epidemic. The rapid growth of the HIV epidemic in many countries has resulted in an equally dramatic rise in the estimated number of new TB cases, which present therefore the integration of HIV and TB testing at the primary level is need of the hour. Methods: A prospective study was conducted on newly diagnosed, untreated TB patients aged 15-45 year and patients were screened for HIV infection. Clinico-radiological spectrum of TB among HIV seropositive and seronegative patients was evaluated. Results: Out of a total of 307 patients screened, 17 (5.54%) were found to be HIV seropositive. Seroprevalence was found significantly (P < 0.01, χ2 9.301) more common in 26-35 year age group and higher in Extrapulmonary TB (EPTB) patients than that in pulmonary TB (PTB) patients (9.90% vs 3.4%). Fever was the most common presenting symptom for TB in HIV seropositive patients. On examination pallor (58.82% vs. 15.86%), oral ulcer (35.3% vs. 0.35%) was found more common and on chest X-ray mid-lower zone involvement and mediastinal lymphadenopathy were more common in HIV seropositive patients. Conclusion: HIV seropositivity rates among newly diagnosed TB patients aged 15-45 year was 5.54 percent. The presentation of TB was more often atypical among these patients. Thus, an integrated model of TB and HIV at primary healthcare service delivery is an efficient use of resources that would address the two very important co-epidemics and thereby result in better management.

A 31-year-old, married female was admitted with complaints of sudden-onset shortness of breath and dry cough since that morning. It was not associated with chest tightness, wheezing or pleuritic chest pain. There was no history of fever, running nose or haemoptysis. The patient had undergone lower-segment caesarean section 2 weeks previously and had reduced mobility since then. She was known to have hypothyroidism for the past 3 years, which was well controlled on thyroxine. On admission, the patient had a respiratory rate of 30 per min, pulse rate of 130 per min, blood pressure of 110/70 mmHg and oxygen saturation by finger pulse oximetry of 89% on room air. Arterial blood gases on ambient air revealed pH of 7.48, carbon dioxide tension of 30 mmHg, oxygen tension of 58 mmHg and bicarbonate of 22 mEq·L−1. Chest radiography did not reveal any significant abnormality. ECG revealed sinus tachycardia, right-axis deviation and T-wave inversion in leads V1–V4., Management of pulmonary embolism in post partum females is a challenge. Lower segment caesarean section in past 3 weeks is a contraindication to systemic thrombolysis. Heparin, fondaparinux and warfarin can be safely used in breast-feeding mothers. http://bit.ly/39Nr7qY

Parenteral anticoagulation is recommended for patients of intermediate - high early mortality risk pulmonary embolism. Rescue reperfusion is considered if signs of hemodynamic decompensation appear. Recent surgery is a contraindication to thrombolysis. Percutaneous catheter directed thrombolysis and surgical embolectomy can be done in such patients. However, they are not readily available. We hereby report a case of rescue thrombolysis in a post lower segment caesarean section (LSCS) patient with pulmonary thromboembolism. We could successfully achieve thrombolysis in our patient with improvement in clinical and hemodynamic parameters and with no major bleeding from any site.

Background: In India, there have been few studies discussing the QOL in lung cancer and work published from developed countries do not reflect the true context of Indian patients. Material and Method: 165 confirmed cases of advanced lung cancer, scheduled for chemotherapy, were enrolled prospectively. The information about QOL of patients was collected before and after chemotherapy, using the EORTC core questionnaire (QLQ C-30 Version 3) and lung cancer module (LC-13) and analyzed as recommended by the EORTC. Results: Mean age of the study group was 54.3 with male to female ratio of 2.8. Of all patients, 156 cases completed the assessment after chemotherapy. The significantly changed quality of life scores amongst EORTC QLQ C30 & LC13 items after chemotherapy are shown in the Table 1. On subgroups analysis between conventional chemotherapy and TKIs, vomiting and hemoptysis score(p =.00) were significantly better with TKIs. Conclusion: This study suggest that chemotherapy may improve QOL in lung cancer patients and using questionnaires to assess the QOL during treatment helps in identifying changes of the QOL and adverse effects of therapy.

Aim: To evaluate effects of stage-matched repeated individual behavioural counselling on basis of Transtheoretical model as an intervention for the decreased and stopping smoking. Material and Methods: The study was conducted in over a period of 1 year where all smokers presenting to OPD were enrolled, each was classified on basis of STAGES OF READINESS TO CHANGE MODEL (Prochaska 1983) and under went repeated counselling for period of 6 months and each session was preceded and succeeded with filling of FAGERSTORM TEST FOR NICOTINE DEPENDENCE. Results: Over a period of 207 patients participated in this study, mean age was 50.74±14.74 years. Mean duration of tobacco use was 29.43±14.72 years. Conclusion: Our intervention also succeeded in increasing the abstinence rates during the study period among smokers with a lower motivation to quit (precontemplators and contemplators) as well as those ready to quit (preparators), this is significant because most existing smoking-cessation interventions target only motivated smokers, with few having a positive effect in smokers with a lower motivation to quit

Introduction: Osteoporosis is one of the extrapulmonary effects of Chronic Obstructive Pulmonary Disease (COPD). Osteoporosis is characterized by low bone mineral density (BMD) resulting in an increased risk of fracture thereby causing significant morbidity and mortality. Aims and Objectives: To determine association between BMD and severity of COPD and association between steroid intake and bone mineral density Material and Methods: 100 new COPD patients were recruited in this study. Diagnosis and severity grading of COPD patients were according to the GOLD guidelines. BMD (at the lumbar spine and at the femoral neck) was performed using Dual energy X-ray absorptiometry (DEXA). BMD was expressed in g/cm2 and standardized T-score and Z-score. Results: Conclusion: There was significant derangement in BMD and T-score in COPD patients which leads to osteoporosis and osteopenia. Patients with history of long term use of oral corticosteroids had more negative values of T –scores at both lumbar spine and femoral neck when compared to inhaled steroids. It is advised to screen for osteoporosis in COPD patients with long term steroid use and who had severe disease.

Electrical injuries though infrequent, are potentially devastating form of injuries which are associated with high morbidity and mortality. The severity of the injury depends upon intensity of the electrical current which is determined by the voltage and the resistance offered by the victim. These injuries vary from trivial burns to death. There have been few reports about pulmonary injuries due to electrical current but none mentioning neurogenic pulmonary edema (NPE). Here we report a young boy who when exposed to high-voltage current developed neurogenic pulmonary edema and was successfully managed. Though there is no specific protocol for electrical injury but identifying the organs involved along with type of disease facilitates the management. How to cite this article Chawla G, Dutt N, Ramniwas, Chauhan NK, Sharma V. A Rare Case of Neurogenic Pulmonary Edema Following High-voltage Electrical Injury. Indian J Crit Care Med 2019;23(10):486–488.

Tuberculin test is an example of delayed hypersensitivity type reaction. Most of the patients develop mild reaction in form of erythema and induration by 24 hours, which reaches epitome at 48 to 72 hours. Hereby the case of a middle aged female who presented with vaginal brownish discharge along with lower abdominal pain and primary infertility has been reported . Transvaginal ultrasonography showed right adnexal mass suggestive of hydrosalpinx. Intradermal tuberculin test was performed which atypically lead to formation of giant bulla of size 30×32 mm by 12 hours. We report this exaggerated response to a standard 5TU tuberculin test, which was later diagnosed as tubercular lymphadenitis with tubercular pelvic inflammatory disease that may be the reason for primary infertility.