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Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; publichealth care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

India has a disproportionately high burden of acute and chronic pulmonary diseases. In India, 65 million suffer from non-communicable respiratory diseases. The outbreak of the novel coronavirus disease 2019 (COVID-19) had worsened the situation. Patients affected with COVID-19 with a previous history of comorbidities, such as COPD and chronic lung diseases, had the worst prognosis, resulting in adverse outcomes, such as acute respiratory distress syndrome (ARDS) and pneumonia. Immune modulation strategies have since gained a lot of traction amongst practitioners. Modulation of the immune system with Pidotimod along with standard-of-care (SOC) treatment has proven efficacious in the past two decades in patients with recurrent respiratory tract infections (RRTIs), bronchitis, COPD, and pneumonia. In this article, we have reviewed the current unmet needs in the management of COPD in India and evaluated the usage of Pidotimod in adult COPD patients based on expert panel discussion.

Background: Patients with chronic obstructive pulmonary disease (COPD) frequently manifest sleep-related breathing disorders. Reported prevalence of significant nocturnal desaturation (NOD) varies from 25-46%,with limited information on its determinants and impact. Aims: To estimate the prevalence,determinants and impact of NOD in stable patients with COPD who are not candidates for domiciliary oxygen therapy. Methods: Consecutive patients with COPD with daytime oxygen saturation (SpO2) >90% with no symptoms or prior diagnosis of obstructive sleep apnea (OSA) underwent overnight level 3 home sleep study. Demographics, spirometry results and COPD assesment test (CAT) questionnaire scores were recorded. Significant NOD was defined as nocturnal SpO2 Results: 42 patients underwent a sleep study. 28 patients (66.7%) had significant NOD. 21 of these patients had an apnea hypopnea index > 15 indicating presence of underlying obstructive sleep apnea (OSA). Recorded day time SpO2 was the only predictor of NOD;all patients with day-time SpO2 Conclusion: Significant NOD is common among patients with COPD. Patients with COPD should be screened for NOD and OSA, especially when the day time SpO2 is less than 96%. This decision to screen should be made irrespective of the stage of the disease and CAT scores.

Background: Exacerbations remain a distinct clinical challenge in Chronic obstructive pulmonary disease (COPD) with consequent use of ICS in real-world practice of India. LAMA add-on therapy has been well highlighted by UPLIFT, TRIBUTE & KRONOS studies. Glycopyrronium add on therapy offers quick control of morning symptoms for likely improved patient adherence rates in COPD Objectives: To assess the clinical impact and use of Glycopyrronium add-on therapy in outpatient settings, real world observational study was planned. Methods and Material: National, post-approval, observational, drug utilization, concurrent analyses was carried out at 128 centers during Sept ’17 with institutional Ethics & CTRI registration. Post-hoc analyses was carried out by Quick Calcs GraphPad Prism ver. 7 software with p

Background: There has been no study on quality of life (QoL) in patients with systemic sclerosis (SSc) in India. Objectives: 1) To determine the difference in QoL in patients with SSc compared to general population. 2) To determine the difference in QoL in subsets of patients with SSc between a) Limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc); b) SSc with and without interstitial lung disease (ILD) c) SSc with disease duration of ≤ 5 yrs and > 5 yrs. 3) To find out the contributing factors to impaired QoL with the help of a newly developed patient reported questionnaire. Methods: In this cross-sectional study, all consecutive adult patients with SSc, satisfying 2013 ACR/EULAR classification criteria, attending a tertiary rheumatology clinic in Western India from January 2016 to March 2017 were compared to age and sex-matched controls. A new questionnaire [Indian Systemic Sclerosis QoL questionnaire (Indian SyS-QoL)] was developed to identify the contributing factors to impaired QoL with feedback from 15 SSc patients and 11 rheumatologists. This questionnaire had 10 factors and each was scored by individual patients between 0-3 (0-no impact; 3-severe impact on QoL in previous month). Demographic data, clinical profile and relevant investigations were recorded. Patients filled Medical Outcomes Trust Short Form 36 version 2 (SF-36v2) questionnaire, Indian SyS-QoL questionnaire and Indian Health Assessment Questionnaire –(Indian HAQ). Results: 94 SSc patients (7 males; 87 females) were compared to 100 age and sex-matched controls. QoL was significantly impaired in patients with SSc compared to healthy controls in all 8 domains of SF-36 (p 5 years [51 patients (54.3%)] and in those with ILD [56 patients (59.6%)] and without ILD [38 patients (40.4%)]. Two most important factors responsible for poor QoL based on Indian SyS-QoL questionnaire score (mean±SD) were ‘feeling of dependency on family’ (1.4±1.3) and ‘cost of treatment’(1.3±1.2)(Fig 1). Conclusion: This maiden study from India showed that QoL was significantly affected in patients with SSc compared to the general population; but there was no significant difference in QoL in patients with different subsets of SSc; disease duration ≤ 5 yrs and > 5 yrs, and presence or absence of ILD. The new graded scale devised to assess the impact of SSc on QoL using a simple patient-reported questionnaire showed ‘Feeling of dependency’ and ‘cost of treatment’ as the 2 most important factors affecting QoL in Indian patients with SSc. This would help direct more resources to support the patients both mentally and financially. References [1] Hudson M, et al. Arthritis Rheum. 2009;61(8):1112–20. [2] Steen VD, Medsger TA. Arthritis Rheum. 1997;40(11):1984–91. Disclosure of Interests: None declared

Objectives: To find out practices related to management of pulmonary TB in new patients, patients not responding to treatment and diagnosis and treatment of drug-resistance in Mumbai’s private sector. Methods: A total of 42 chest physicians (CP), 51 post-graduates in general medicine (MD), 70 allopathic graduates (AP) and 33 ayurvedic/homeopathic physicians (ISM) participated in this cross sectional study. A pre-designed pilot tested questionnaire was used to collect data. Practices of physicians were compared with the International Standards for Tuberculosis Care (ISTC). Results: Most physicians across all groups reported use of sputum microscopy for diagnosis. ISTC recommended regimens were prescribed by 11 (29%) CP, 15 (31%) MD, 6 (9%) AP and 3 (9%) ISM practitioners for treatment of new pulmonary TB patients. 18 (43%) CP, 13 (26%) MD, 19 (27%) AP and 6 (18%) ISM practitioners prescribed retreatment regimen without investigating for drug-resistance among patients not responding to first regimen. Regimens prescribed by 6 (25%) CP and 3 (9%) MD for treatment of multidrug-resistant TB were as per ISTC recommendations. The specialists (CP and MD) were significantly more likely than family physicians (AP and ISM) to adhere to ISTC recommendations related to diagnosis, treatment and monitoring of new TB cases. Conclusions: Management of TB among new patients was deviating from ISTC recommendations more so among AP and ISM than in CP and MD groups. There is a delay in suspecting drug-resistance in private sector. Majority of regimens offered for treating multidrug-resistant TB are not individualised and most are inadequate. There is a need to train physicians in Standards for TB Care in India (STCI).

Contents: Executive Summary Introduction Methodology Definition, Epidemiology and Risk Factors Diagnosis of Asthma Management of Stable Asthma Management of Acute Exacerbations of Asthma Miscellaneous Issues in Asthma Management

Recent years have seen an increase in the use of nebulizers for delivering maintenance therapy in obstructive airway diseases (OADs) such as asthma and chronic obstructive pulmonary disease (COPD). The probable factors associated with this increase at home are: convenience of drug delivery, technological advances making the nebulizer equipment more efficient and portable, increase in the prevalence of OADs and the ageing population which may impact the optimal use of handheld inhalers such as pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). Although there is increase in the use of maintenance therapy with nebulization, there has been no such increase in the evidence base available for the appropriate use of nebulizers. The last international guidelines were published in 2001. Hence there is a need to address this knowledge gap especially with the widespread use of home nebulization in India. With this objective, we organized a consensus meeting to address certain critical questions pertaining to the use of nebulizers for maintenance treatment in OADs. This article presents the findings of the consensus panel on the use of maintenance treatment of OADs with nebulization at home.

To the Editor,In the present journal, a recent review on Mycobacterium tuberculosis emphasized the importance of adequate concentrations of antibiotics to counteract development of resistance [1]. ...

Pidotimod, an immunostimulant, is researched for over two decades. Current evidence indicates its utility in a variety of indications in children as well as in adults. Its immunostimulant activity has been firmly established in the management of recurrent respiratory infections in children with or without asthma. Compared to standard of care alone, addition of pidotimod to standard of care significantly prevents the recurrences and reduces the severity and duration of acute episodes, ultimately resulting in reduced visits to pediatric clinics and lower absenteeism at school. In adults, pidotimod is effective in the prevention and treatment of acute infectious exacerbations of chronic bronchitis and chronic obstructive pulmonary disease (COPD). Further, it has been evaluated in indications such as pneumonia, hand-food-mouth disease, bronchiectasis, and chronic idiopathic urticaria. From a total of 32 studies conducted in child (24 studies) and adult (8 studies) population, this in-depth review discusses the current evidence of pidotimod. With further exploration, the immunostimulant activity of pidotimod might be extended to different immunological disorders.

Globally, pneumococcal diseases are a significant public health concern. They are preventable and frequently occur among older adults. Major risk factors for the disease are extremes of age, alcohol intake, smoking, air pollution, and comorbid conditions (diabetes, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, and heart disease). Risk factors, coupled with limited disease-burden data and the emergence of antibiotics resistance, are hindering the effective management of the disease in older adults. Various global guidelines recommend pneumococcal vaccines for the prevention of pneumococcal diseases, as they reduce disease burden, hospitalization, and mortality rates among patients with comorbid conditions. Besides being an integral part of childhood immunization, these vaccines are advocated by various Indian healthcare bodies/groups for older and younger adults with certain medical conditions. The article presents an overview of the closed-door discussion by the Indian pulmonary experts on the scientific evidence and clinical practice followed for the prevention of pneumococcal disease in India.

Therapeutic Drug Monitoring (TDM) is a routinely practised clinical laboratory technique which aids the clinicians with a clear clinical judgement of the drug therapy and optimize the doses if necessary. Rifampicin is the most important and potent component of first line therapy of tuberculosis (TB). Several factors like age, weight, gender, doses and formulations, gastro-intestinal disorders, ethnicity etc alter the absorption and bioavailability of rifampicin thus altering the drug levels. Low plasma levels of rifampicin may play a plausible role in slow response to therapy, treatment failure or relapse or acquired drug resistance. TB Patients with further complicated conditions like diabetes or HIV are at an increased risk for poor drug absorption and drug-drug interactions. A standard treatment regimen may be inadequate for some cases as the clinical status of patients vary from case to case. TDM can be used as a clinical tool for identifying patients at high risk of treatment failure, delayed response, drug-drug interactions and help optimization of therapy. In the past two decades numerous reports of TDM of anti-tuberculosis drugs have been reported wherein low rifampicin levels have been a major concern. Rifampicin exhibit concentration dependent killing of mycobacteria. A 2 hour post-dose sample approximates the peak plasma rifampicin concentration (Cmax) and is recommended for TDM of rifampicin. An additional 6 hour sample may be collected to distinguish between delayed absorption and malabsorption. Combined with clinical and bacteriological data, TDM can help clinicians treat slow response / complicated TB patients.

Sarcoidosis is a chronic, systemic disease of unknown etiology that affects multiple organs. The disease was considered rare in developing countries like India. More recently sarcoidosis is being increasingly diagnosed in countries where tuberculosis continues to be endemic. There is a general perception among physicians that the prevalence of sarcoidosis has increased over the last two decades in countries like India. This may be true but could also be related to better awareness of the condition, availability of improved diagnostic facilities and the increased ability of physicians to differentiate it from tuberculosis. In India, diagnosis of tuberculosis is entertained first in patients who may have sarcoidosis and thus, it is very likely for sarcoidosis to be misdiagnosed as tuberculosis, owing to the high prevalence of tuberculosis and clinicoradiological resemblance to the disease. This editorial highlights the challenges in diagnosing tuberculosis in countries where tuberculosis still continues to be endemic.

Cough is the most common symptom for which medical treatment is sought in the outpatient setting. Chronic dry cough poses a great diagnostic and management challenge due to myriad etiologies. Chronic cough has been commonly considered to be caused by gastroesophageal reflux, post-nasal drip or asthma. However, recent evidences suggest that many patients with these conditions do not have cough, and in those with cough, the response to specific treatments is unpredictable at best. This raises questions about the concept of a triad of treatable causes for chronic cough. This article discusses the mechanism and etiology of cough, along with recent advances in the field of cough, highlighting some of the diagnostic and management challenges.

Lymph node tuberculosis (LNTB) is one of the most common extrapulmonary manifestations of tuberculosis. A high index of suspicion is needed for diagnosis of tuberculous lymphadenitis, which is known to mimic numerous pathological conditions. Availability of molecular technology has improved the ease of diagnosis. Molecular techniques are also useful for the early detection of drug resistance. With the advent of endobronchial ultrasound in the last decade, the diagnosis of mediastinal tuberculosis has also improved. Management of LNTB often has difficulties. However, most cases can be managed medically and surgical intervention is rarely required. The treatment is similar to pulmonary tuberculosis. However, paradoxical reaction, which is observed in 10–15% of immunocompetent and about 50% of human immunodeficiency virus positive patients needs a special mention for an appropriate management of LNTB.

Objective: To analyze the usefulness of the Mantoux test in the diagnosis of genital tuberculosis in women of childbearing age. Method: In this report, the investigators studied the ability of a tuberculosis (TB) Mantoux test to diagnose pelvic tuberculosis. A positive TB Mantoux test was clearly defined. The positive control group was of 100 women treated for TB (study group C). The negative control group was of 100 postpartum women (study group B). The study group was 100 infertile women undergoing laparoscopy, in some of whom the diagnosis of TB was made (study group A). Result: The Mantoux test had a sensitivity of only 55% and a specificity of 80% in women with laparoscopically diagnosed tuberculosis. Pelvic focal reaction was absent in all groups including infertile women with a positive Mantoux test. Conclusion: Mantoux test has limited utility in diagnosing active genital tuberculosis during the childbearing age. However, in infertile women with positive a Mantoux test, laparoscopy may be advocated early.

Background Pulmonary involvement, including both interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), has become the primary cause of Scleroderma-related death. Little data has been published from India regarding the progression of ILD and Pulmonary arterial hypertension in Scleroderma. Objectives 1) To identify baseline factors predictive of ILD and its outcome in patients with Scleroderma. 2) To study the progression of ILD and PAH in scleroderma patients 3) To study the demographic and clinical profile of scleroderma patients from Western India. Methods Prospective observational study involving 68 patients. Patients were evaluated at 0,3,6,9 and 12 months. Patient9s demographic and clinical details were recorded at baseline. Other than routine tests, Anti-nuclear antibodies (ANA), Spirometry, diffusing capacity of lung for carbon monoxide (DLCO) measurement, high resolution computed tomography (HRCT) of thorax, 6-minute walk test and echocardiography were done. Results Study included 68 individuals with Scleroderma (according to the American College of Rheumatology classification criteria for SSc) with majority of cases being females n=64 (94.1%). ILD was seen in 53 (77.9%) patients with a mean duration of 4.17 years. When we compared the mean change in FVC, DLCO and PAH from the time of onset of ILD/PAH to the values at last follow up, there was no significant change. ILD patients with UIP pattern on HRCT, showed a significant progression in terms of >10% fall in FVC as compared to NSIP subgroup. None of the baseline parameters were predictive of ILD and its progression. Older age predicted onset of PAH. Conclusions 1) None of the studied baseline variables were predictive of ILD and its progression. 2) Only age had statistically significant effect as a predictor for the occurrence of PAH. 3) The demographic and clinical profile of our cohort was comparable to other studies from India and western population. Calcinosis and telangiectasia were less frequently seen as compared with western population. References Kumar U, Ramteke R, Yadav R, Ramam M, Handa R, Kumar A. Prevalence and predictors of pulmonary artery hypertension in systemic sclerosis. J Assoc Physicians India. 2008 Jun;56:413–7. Disclosure of Interest None declared

Pseudallescheria boydii and its asexual state Scedosporium apiospermum is a well known opportunistic pathogen among immunocompromised patients. However it is rare in immunocompetent patients. The optimum management of this infection is still not clear. The new azoles may show better efficacy than amphotericin B and additional surgery may play a pivotal role. We report a case of Pseudallescheria boydii lung infection in an immunocompetent patient who had an old tuberculous cavity and presumed inhalational exposure. The case highlights difficulties in diagnosis which complicates the selection of antifungal agent/s and the need for aggressive surgical debridement.

The efficacy and safety of the fluoroquinolone pefloxacin was evaluated in 55 patients with nosocomial respiratory tract infections. Eighteen patients had bronchiectasis, 14 had chronic obstructive pulmonary disease, 9 had lung abscess, 6 had pneumonia, 3 had bronchial asthma with infection, 2 had interstitial lung disease with infection, and 1 patient each had empyema, infected lung cyst, and hydropneumothorax. All patients suffered from cough. Forty-two (76%) of the 55 patients had dyspnea, 33 (60%) had rhonchi, and 22 (40%) had fever. Klebsiella and Pseudomonas species were isolated from the sputum of 18 and 17 patients, respectively. Two patients were infected with Acinetobacter , 3 with staphylococci, 2 with streptococci, 2 were infected with Streptococcus pneumoniae , and 1 each with Haemophilus influenzae , and Escherichia coli . In 12 patients, no organisms were isolated from the sputum. All patients were treated with pefloxacin 400 mg twice daily for 10 to 14 days. In 36 (84%) of the 43 patients with positive cultures, pefloxacin therapy eradicated the organisms. The organisms persisted in seven (16%) patients. Clinical cure was observed in 10 (18%) of the 55 patients, improvement was seen in 39 (71%) patients, and failure occurred in 6 (11%) patients. Pefloxacin therapy did not affect biochemical values. One patient complained of mild headache, but this side effect was not directly attributable to pefloxacin treatment. Pefloxacin should be considered as an alternative to multi-drug therapy for the treatment of nosocomial respiratory tract infections.