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Introduction: Chronic Obstructive Pulmonary Disease (COPD), a globally prevalent disease holds a huge stake among all pulmonary patients being admitted throughout the year. Various disease specific and health related quality of life questionnaires such as the Constructed Response Question (CRQ) and St. George’s Respiratory Questionnaire (SGRQ) are readily available, although, attributing to their complex structure, they can’t be used in a widespread manner. Some new scores like COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) were developed to ease-off this dilemma. However, there is a need to justify usage of these patient-friendly simplified scores by objectifying their inter-score reliability and correlation with disease severity and progression using statistical analysis. Aim: To analyse efficacious use of CAT, CCQ score and modified Medical Research Council (mMRC) scale in assessing health status of COPD with exacerbation. Additionally, it was also targeted to assess the inter-score correlation and reliability. Materials and Methods: A total of 180 confirmed cases of COPD with exacerbation were included in this study and subjected to requisite biochemical parameters, assessment scores at their admission, after 1 week and then after 4-6 week (at stabilisation) and spirometry. 136 patients were followed-up to 4-6 weeks and studied. Quantitative and qualitative variables thus obtained were compared statistically to find out correlation, if any. A p-value of <0.05 was considered significant. Results: Mean difference between CAT score at exacerbation and at 1 week and CAT score at exacerbation and at 4-6 weeks were statistically significant. The changes in CCQ scores from exacerbation to 1 week and 6 weeks were also found to be statistically significant. Similar pattern was also observed in assessing timescale variability of mMRC score. There was good correlation between CAT, CCQ and mMRC scores at exacerbation, 1 week and it continually intensified as patients progressed towards a more stable state (4-6 weeks). Similar pattern was also observed with significant progressive positive correlation between change in CAT, CCQ and mMRC scores from exacerbation to 1 week and from exacerbation to 4-6 weeks. Conclusion: These score have a high correlative reliability when used to assess health status among various stages of disease from exacerbation towards a stable state. Similarly, correlation between change of individual score from exacerbation towards recovery state was also high. [ABSTRACT FROM AUTHOR]

Background: Chronic obstructive pulmonary disease (COPD) has a major impact on health status in accordance with disease severity. It is usually assessed by the various quality of life questionnaires. Objectives: The aim of this study is to assess the disease severity and health status in stable patients of COPD using COPD assessment test (CAT) and clinical COPD questionnaire (CCQ) scores and to correlate with BODE index and its components. Methods: One hundred patients of stable COPD were subjected to CAT, CCQ irrespective of the stage of COPD during their visit. BODE index was also calculated. Results: COPD severity status assessed using forced expiratory volume 1% (FeV1%) predicted values correlated significantly with individual scores (CAT and FeV1%; r = -0.67; P < 0.001 and CCQ and FeV1%; r = 0.61; P < 0.001). CAT and CCQ score also correlated significantly (r = 0.84, P < 0.001) and both with the BODE index (r = 0.80; CAT and r = 0.66; CCQ, P < 0.01). Individual components of BODE index significantly correlated with CAT and CCQ scores. Conclusions: The CAT and CCQ have similar psychometric as well physical properties to assess the health status of COPD patients and can be used as a reliable scientific research tool and can be used in clinical practise to study the disease state and plan an appropriate treatment plan. The BODE index which is more objective, correlated well. [ABSTRACT FROM AUTHOR]

Background: Sometimes etiological diagnosis of pleural effusion is difficult despite cytological, biochemical and microbiological tests and labeled as undiagnosed exudative pleural effusions. Aim of present study was to make an etiological diagnosis of pleural effusion. Materials and Methods: Study group included patients of exudative pleural effusion where etiological diagnosis could not be yielded by conventional cytological, biochemical and microbiological investigations. Pleural tissue was obtained by Cope's pleural biopsy needle and or thoracoscopy. Pleural biopsy was subjected to histopathology, ZN staining and culture to find the mycobacterium tuberculosis. Results: Out of 25 patients, 17 (68%) and 8 (32%) were male and female, respectively. Age ranged from 15 to 65 years (mean 31.72). Mean value of serum and pleural fluid LDH was 170.56 U/L and 1080.28 U/L, respectively. Histopathology of 9 (36%) showed epitheloid granuloma with caseation necrosis. In other 9 (36%) patients, epitheloid granulomas (with or without giant cells) was reported. In 5 (20%) patients, histopathology report was of nonspecific chronic inflammation. Histopathology was reported as normal in one case; it turned out to be a case of malignancy. In two (8%) patients, pleural tissue obtained was inadequate for opinions; however, other tests revealed malignancy in one and tuberculosis in other. Ziehl-Neelsen (ZN) stain was positive for AFB in two patients and culture of pleural tissue showed presence of Mycobacterium tuberculosis in three patients. Conclusions: The role of percutaneous closed needle biopsy of pleura among patients of undiagnosed exudative pleural effusion is still accepted as a diagnostic tool, as this may lead to a specific diagnosis among 76% of cases. This is of particular importance in a developing country like India where the facilities of thoracoscopy and imaging guided cutting needle biopsies are not easily available. [ABSTRACT FROM AUTHOR]

Introduction: Hyperphosphatemia is a well known complication of chronic kidney disease. Significant morbidity and mortality particularly due to cardiovascular diseases is associated with high level of phosphate. Measures to control phosphorus level include dietary phosphorus restriction, dialysis, and oral phosphate binders. Currently most common treatment for this condition is oral phosphate binders. Lanthanum carbonate (Fosbait®) is newly introduced compound in this genre. Aims and Objectives: This study aimed to evaluate the efficacy and safety of lanthanum carbonate (Fosbait®) in Indian patients with hyperphosphatemia associated with CKD. Materials and Methods: Total 31 CKD patients, stage 3 and 4 (predialysis) and stage 5 (dialysis) with serum phosphorus level > 5.5 and > 5.9 respectively, were recruited in the study over the duration of 10 months. All hypophosphatemic agents were withdrawn during the washout period, vitamin D analogues were continued. All patients were given lanthanum carbonate (Fosbait®) in chewable tablet form, in dose range of 750 mg to 2250 mg a day in three divided doses immediately after throe major meals. Levels of serum phosphorus and calcium were assessed fortnightly, while level of iPTH was measured on week 0 and week 10. Dosage was titrated accordingly up to six subsequent weeks and thereafter dose of the drug was kept constant till 10 weeks. Result: Mean age of patients was 46.85 years and male to female ratio was 1.6:1. We noted 36.49%reduction in mean serum phosphorus level (from 6.47±0.84 mg/dl to 4.11±0.72 mg/dl, P= 0.005). Significant reduction in serum phosphorus level was observed in 87.5% of dialysis and 84.61% of non dialysis patients. Reduction in mean serum iPTH was 10.20% (from 181.86±19.8 pg/ml to 163.30±23.2 pg/ml, P=0.408). Mean serum calcium phosphorus product reduction by 31.83% had been noted (from 59.54±10.5 to 25.94±13.4, P=0.005). Reduction of mean serum calcium level was noted by 21.68% (from 8.96±1.1 to 7.50±1.4, P=0.005). Side effects observed were body ache in 26% of the patients, anorexia, abdominal pain, dysphagia, dry mouth and diarrhea in 11.5% patients. Conclusion: We conclude that lanthanum carbonate (Fosbait®) is effective in correcting hyperphosphatemia in indian CKD patients with tolrable side efeects. [ABSTRACT FROM AUTHOR]

Background: Sleep disorders are common in patients with renal failure on dialysis. The prevalence of 'poor sleep' and various sleep disorders like sleep apnea syndrome is very high in these patients when compared to general populations. It is hypothesized that this poor sleep quality adversely affects the health related quality of life (HRQL). Aim of the Study: This study aimed to measure the exact prevalence of various sleep disorders including sleep apnea syndrome, in CKD patients on maintenance hemodialysis, both subjectively and objectively, and to study the effect of these sleep related disorders on health related quality of life (HRQL). Materials and Methods: This study consisted of 100 patients, on regular maintenance hemodialysis for at least 2 months duration. They were subjected to routine hematological and biochemical investigations, followed by Epworth sleep scale (ESS) to assess daytime sleepiness. Quality of sleep was assessed subjectively by Pittsburgh Sleep Quality Index (PSQI) and objectively (in a subset) by overnight polysomnography. Further, Health Related Quality of Life was assessed by medical outcome study 36-item short form (SF-36) questionnaire. Data generated was analyzed for correlations with SPSS software. Results: Daytime sleepiness, as assessed by ESS was found to be high with a mean score of 10.9 ± 5.5, and 53 % patients had a score ≥ 10. Mean value forglobal PSQI score was 10.3 with worsening of quality in almost all the domains. Seventy seven percent patients were poor sleepers (global PSQI < 5) and compared to good sleepers, poor sleepers had a greater proportion of obese patients, lower hemoglobin, higher urea and creatinine, higher mean ESS score, lower sleep efficiency, higher desaturation index, respiratory disturbance index and higher PLM index. Health related quality of life as assessed by SF-36, had 2 summery components; PCS and MCS (physical and mental component summery). Mean score for PCS and MCS were 43.5±10.5 and 50.7±14.3, respectively. Further, good sleepers had better scores in both PCS and MCS domains in comparison to poor sleepers. Eighty six percent patients reported worsening of health status in comparison to last year. Quality of sleep correlated with quality of life in most of the domains with significant P value. Conclusions: In conclusion, the results of this study suggest that poor quality sleep and various sleep disturbances like sleep apnea syndrome are common in dialysis patients and quality of sleep is an important negative predictor of health related quality of life. [ABSTRACT FROM AUTHOR]

Background: To identify the patients of bronchial asthma (suspected or proven), not responding to optimal therapy, for the presence of vocal cord dysfunction (VCD) and to compare the diagnostic ability of flow volume (FV) loop and impulse oscillometry (IOS)., Materials and Methods: Fifty one patients of suspected/proven bronchial asthma not responding to optimal therapy were included for the study. Each patient was subjected to both FV loop and IOS studies. Direct visualization of the vocal cords with flexible fiberoptic bronchoscope for the presence of inspiratory vocal cord adduction during quiet respiration, with speech, and while performing provocative maneuvers was carried out. All patients were subjected to simple pulmonary function tests and recording of FV loop. IOS was performed on each patient to look for the site of obstruction and upper airway influence. The observations of both FV loop and IO studies were compared., Results: Among 51 patients participated, 12 (23.53%) had bronchoscopical evidence of VCD and were labeled as VCD-positive group and rest 39 were designated VCD negative. No statistically significant difference in pulmonary function test (prereversibility) results between the VCD-positive and VCD-negative patients was found. Reversible airway obstruction was observed in 75% of the patients of VCD-positive group and 67.65% of the patients in the VCD-negative group. Only one patient in the VCD-positive and none in VCD-negative group had inspiratory limb flattening of FV loop. Upper airway influence was evident by IOS in 58.3% of patients in the VCD-positive group and in 15.4% of patients in the VCD-negative group. This difference was statistically significant (P< 0.005)., Conclusion: VCD was a common finding in patients with symptoms suggestive of asthma and frequently coexists with asthma. IOS was found to be a useful screening test for VCD and was more sensitive than FV loop.

A 34-year-old lady presented with generalised weakness of body, indistinguishable from myasthenia gravis within 24 hours of a wasp sting. Respiratory muscle paralysis leading to respiratory failure developed and mechanical ventilatory support was required. The patient made an uneventful recovery.

A 35-year-old women presented with breathlessness and features suggestive of pulmonary hypertension. Further investigations revealed that she had autoimmune hepatitis and both portal and pulmonary hypertension. Pertinent literature is reviewed.

Objectives: Hepatopulmonary syndrome consists of a triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatations and hypoxemia. A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension was undertaken., Methods: Thirty patients participated in this study. The diagnosis of cirrhosis of liver was confirmed by liver biopsy. Arterial blood gas analysis, pulmonary function tests, two-dimensional transthoracic air contrast echocardiography were undertaken in all the patients. Those patients in whom contrast echocardiogram showed intrapulmonary vascular dilatations were classified as the positive group while others were labelled as the negative group., Results: Ten patients (33.33%) had a positive contrast echocardiogram; five (16.67%) of them were found to have PaO2<70 mmHg and were qualified for the diagnosis of hepatopulmonary syndrome (HPS); and other five (16.67%) with PaO2>70 mmHg were diagnosed as intrapulmonary dilatations syndrome (IPVDS). Five patients of HPS revealed significant P(A-a)O2 gradient and intrapulmonary shunts of moderate severity computed by a/A ratio. Cyanosis (p=0.001), clubbing (p=0.009) and orthodeoxia (p=0.0024) were significantly commoner in the five patients of hepatopulmonary syndrome. Presence of spider naevi was significantly related with the presence of intrapulmonary vascular dilatations., Conclusions: The study results showed presence of hepatopulmonary syndrome and intrapulmonary vascular dilatation syndrome among patients of portal hypertension. The presence of cyanosis, clubbing and orthodeoxia were found to be suggestive indicators of hepatopulmonary syndrome. Even though not very specific, spider naevi were found to be a useful clinical indicator for the presence of intrapulmonary vascular dilatations.

Study Objective: Ventilator-associated lower respiratory tract infection (LRTI) in a set up of respiratory intensive care unit was evaluated. Also the incidence of tracheobronchial aspiration of gastrointestinal contents was explored among these patients., Design: Twenty eight patients admitted in the respiratory intensive care unit of referral teaching hospital were studied. All patients were evaluated for tracheobronchial aspiration of gastrointestinal contents in the initial 48 hours of initiating mechanical ventilation using methylene blue as marker and glucostix reagent strip. Protected endotracheal aspirate was secured after 48 hours of beginning of mechanical ventilation and was submitted for microbiological assay., Results: Of the 28 mechanically ventilated patients, 82% were found to have developed LRTI. Aerobic gram-negative bacilli accounted for 79% of the infections, Klesiella responsible for 39% while Pseudomonas and Escherichia accounted for 18% each. The remaining 4% were caused by Acinetobacter. Gram-positive cocci were responsible for 21% of infection with Staphylococcus and enterococci 14% and 7% respectively. Tracheobronchial aspiration of GI contents was found to be present in 72% of the patients which was significantly correlated with the incidence of LRTI (p=0.014). Significant association was also found between the incidence of LRTI and mortality (p=0.05)., Conclusion: The incidence of gastrointestinal aspiration was found to be high and correlation with LRTI was significant. Both glucostix reagent strip and methylene blue were observed to have same positivity rate.

A young boy who sustained blunt chest trauma 24 months back, presented with repeated chest infections. His chest skiagram revealed right hemithorax opaque and CT scan of thorax showed collapse of right lung. Fiberoptic bronchoscopy helped to diagnose the post-traumatic stenosis of right main bronchus. Laser resection was utilized to restore the patency.

Vocal cord dysfunction (VCD) is a relatively rare condition that may mimic asthma or upper airway obstruction. In contrast to initial reports, recent work emphasizes that patients with VCD often may have both asthma and VCD concurrently. VCD presents a formidable diagnostic challenge. Spirometry often gives variable results. The diagnosis is confirmed at direct laryngoscopy by observing abnormal vocal cord movements without other pathologic processes. Therapy of VCD involves removal of unnecessary medications, efforts to minimize vocal cord irritation, and aggressive speech therapy. In selected cases, anxiolytic medications and psychiatric consultation may be beneficial.

Objectives: Till a decade back, the mainstay delivery of mechanical ventilation to patients with acute respiratory failure was through the endotracheal tube. To obviate the various complications of endotracheal intubation, noninvasive mechanical ventilation (NIMV) techniques were devised which could be used outside the confines of an ICU setting, and have been employed by several workers to achieve a high success rate., Methods: Twenty patients of acute respiratory failure (ARF) were treated with NIMV. The latter was delivered by assist control mode of ventilator and nasal CPAP mask. Improvement of the illness was monitored by serial ABG analysis and breathing pattern parameters over one week., Results: The application of NIMV was successful in reversing the illness in 17 patients (85%) and the other three patients had to be intubated. The pH rose from 7.267 +/- 0.087 at presentation to 7.411 +/- 0.032 (p < 0.00005), the PaCO2 dropped from 85.17 +/- 13.48 mmHg to 46.27 +/- 3.79 mmHg (p < 0.00005). The PaO2 improved from 52.36 +/- 11.14 mmHg to 63.60 +/- 7.55 mmHg (p < 0.005) on the seventh day. The respiratory rate (RR) decreased from 30.07 +/- 6.10 breaths/min to 22.05 +/- 4.05 breaths/min (p < 0.00005), the %RC (percent rib cage) also showed a significant reduction in rib cage contraction from 61.7 +/- 10.17 to 42.76 +/- 10.66 (p < 0.00005). A marked improvement during the initial four hours of application of NIMV was observed in all the 17 patients., Conclusions: It was concluded that NIMV resulted in marked improvement in both the breathing pattern and blood gas parameters in patients of ARF; and PaCO2, pH, RR, %RC served as the best indicators of improvement. NIMV was observed to be most useful in those patients who had CO2 retention.

The patient with goiter and his or her physician frequently overlook symptoms of upper respiratory obstruction. Conventional radiology is the accepted method for detecting upper airway obstruction in these patients. Flow volume loops provide additional information on airflow dynamics. Twenty-five patients of goiter undergoing surgery were evaluated for upper airway obstruction by symptomatology, conventional radiology, and flow volume loops. Flow volume loops were repeated 1 month after surgery. Ten (40%) patients had mild symptoms on direct questioning. Tracheal deviation, compression, or both were noted in eight (32%) patients on radiology. Flow volume loops detected upper airway obstruction in 15 (60%) patients. Surgery resulted in normalization of all preoperative abnormal curves. The flow volume loop is a simple noninvasive method for detecting upper airway obstruction in patients with goiter. Abnormal upper airway dynamics are present in more patients with goiter than previously recognized, and relief of this obstruction should be an important aspect of thyroid surgery.

Objective: There is an association of sleep apnea among patients with untreated hypothyroidism. Thyroxine therapy is considered to reduce AHI (apnea-hypopnea index) significantly. A study of 20 successive hypothyroid patients was undertaken to investigate the occurrence of sleep apneas, and response to thyroxine therapy after achieving euthyroid state., Methods: Sleep studies were conducted in 20 consecutive hypothyroid patients at our sleep centre while they were hypothyroid. All were restudied during euthyroid state subsequent to three months of thyroxine therapy., Results: Nine (45%) of untreated 20 patients had obstructive sleep apnea syndrome (OSAS). Restudy of them during euthyroid state showed complete recovery in six, partial improvement in two and no change in one. Besides them, three other patients developed sleep apnea syndrome of central origin after euthyroid state was achieved. Central respiratory drive improved in 17 patients, while it was reduced among three of nine patients with OSAS who did not show recovery., Conclusion: Our experience suggests that there is high incidence of sleep apnea among hypothyroid patients. Thyroxine treatment could achieve disappearance of these apneas in majority of them. Few hypothyroids may develop sleep apnea despite the achievement of euthyroid state. Central respiratory drive probably plays an insignificant role in the pathogenesis of sleep apnea among hypothyroids.

Twenty eight of 48 patients diagnosed of obstructive sleep apnea syndrome over a six month duration opted for CPAP therapy. Half of them were given critical CPAP (Group A) and other half were prescribed subcritical level of CPAP (Group B). Re-evaluation after 3 months revealed that side effects like headache and feeling of inconvenience were more in Group A, though beneficial effects were same in both groups. It is concluded that subcritical level of CPAP should be adopted to treat patients of obstructive sleep apnea syndrome.

Twenty patients of interstitial lung disease (ILD) and same number of healthy adults were selected to monitor arterial hemoglobin oxygen saturation (SaO2) breathing pattern and arrhythmias during sleep. The maximum fall in SaO2 during sleep was 13.1% (10-16%) in ILD patients as compared to 4.8% (3-6%) in controls and the difference was significant (p < 0.005). The ILD patients spent 16.9% of mean total sleep time (TST) below 85% SaO2 and 0.7% of mean TST below 80% SaO2 whereas none of the healthy subjects had SaO2 below 90% during sleep. These patients had more disturbed sleep than controls. Abnormally high breathing frequency demonstrated by ILD patients while awake, was not altered during sleep. Both tidal volume (VT) and minute ventilation (Vmin) decreased by 6.6% and 11.5%, respectively in ILD patients during sleep though it was not significant (p > 0.25) statistically. The respiratory drive was declined during sleep in ILD patients. The percent of tidal volume contributed by rib cage (% RC) lessened during sleep in all the subjects. The ratio of the total excursion of the rib cage and abdomen during inspiration without considering the direction of movement, divided by tidal volume (TCD/VT) revealed asynchronous breathing in ILD patients during sleep. Arrhythmias were found in 6 (30%) of ILD patients and 4 (20%) of control subjects. Observed apnea-hypopnea did not qualify for sleep apnea syndrome in any case.

Twenty-five cases of upper airway obstruction (UAO) of different diseases and ten normal healthy controls were studied by deriving parameters from raw data on Gould System-21 Pulmonary Work station. All the obstructive lesions were confirmed under direct visualisation by fibreoptic bronchoscopy or indirect laryngoscopy. It was observed that FEF 50%/FIF 50% ratio above 1 was the best diagnostic indicator for fixed and variable extrathoracic UAO (p < 0.02). FEV1/PEFR was altered significantly (p < 0.001) and value above 10 ml/Litre/min was the second best parameter to recognise UAO. FEV1 0.5 < or = 1.5 (p < 0.001) and FIF 50% < 100 Lit/min were also suggestive of UAO. Flow volume loop remained the most sensitive method to detect UAO but only 15 patients could construct it. These altered parameters returned to normal after the surgical removal of obstruction which was possible in three cases.

A questionnaire regarding use of metered dose inhalers (MDI) was administered to 38 physicians, 9 faculty members and 29 residents. Fifty-five percent of faculty members answered at least three or more of the seven steps of inhalation technique correctly as compared with 86% of residents, this was statistically significant (p value < 0.01). All the participants used to prescribe MDI to their patients. 80% of them responded that they followed package insert instructions to educate their patients. It was concluded that doctors involved with MDI use, should learn and become familiar with proper recommendation for its optimal aerosol delivery.

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

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

A case of chronic pancreatitis with multiple pseudocysts of the pancreas and a pancreatico-pleural fistula causing massive left sided pleural effusion is reported, being a rare and an unusual cause of pleural effusion. This case illustrates the importance of pleural fluid amylase estimation in the diagnosis and the role of endoscopic retrograde cholangio pancreatography to elucidate the pathogenesis of such an effusion. The role of medical management is also emphasized.