Lungs

Endobronchial metastasis: The challenge continues Neeraj Gupta Lung India 2019 36(3):181-182

New combined assessment of chronic obstructive pulmonary disease: Utilization, pitfalls, and association with spirometry Ruchi Dua, Ranjeeta Kumari, Vivek Yadav, Mayur Ranjan, Subodh Kumar, Mayank Mishra, Suryakant Tripathi Lung India 2019 36(3):183-187 Introduction: Classification of chronic obstructive pulmonary (COPD) disease has changed from being solely based on spirometric variables to combined assessment including symptom scores and history of exacerbations/ hospitalizations. There is both lack of awareness regarding change in its assessment as well as underutilization due to time constraints and seeming complexity. Moreover, treatment of COPD needs to be tailored according to the new combined assessment. Aims: Current study was planned to look at current stratification of patients according to new revised combined assessment (Global Initiative for Chronic Obstructive Lung Disease GOLD 2017) in comparison to old(GOLD 2011) as well as its incorporation in clinical practice. Co-relation between revised combined assessment and spirometric staging was also assessed. Methods: 418 consecutive COPD patients were enrolled, their dyspnea scores in terms of modified medical research council scale (mMRC), preceding history of hospitalization/ exacerbation over preceding one year and spirometric variables were recorded. Their stratification according to old and new classification recorded. Their past treatment records were reviewed and combined assessment if done recorded. Results: Substantial shift of categories is seen from C and D respectively to stage A and B on applying the new classification compared to old i.e more severe to less severe. Secondly, revised combined assessment is still highly underutilized. Revised combined assessment has positive co-relation with spirometry and post bronchodilator forced expiratory volume in 1 second(FEV1). Conclusions: Management of substantial number of stable COPD patients may need to be stepped down in accordance with revised combined assessment. There is a need to disseminate information regarding change in COPD classification and stress on its incorporation in our day-to day clinical practice. Revised combined assessment has positive co-relation with spirometry, stressing its utility even in peripheral centers without spirometry facilities.

Exacerbation of chronic obstructive pulmonary diseases as a risk factor of the skeletal muscle dysfunction Vitalii Poberezhets, Yuriy Mostovoy, Hanna Demchuk Lung India 2019 36(3):188-192 Background: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) contributes to increased systemic inflammation, oxidative stress, hypoxia, hypercapnia and other risk factors of the skeletal muscle dysfunction. Aims and Objectives: This study aimed to determine whether the frequency of the COPD exacerbations promotes deterioration of the skeletal muscle dysfunction in patients with COPD and to figure out which characteristics of the muscles will reflect this changes. Materials and Methods: We examined 98 male COPD patients, mean age 60.4±11.2 years, GOLD groups B, C, D. To assess the degree of skeletal muscle dysfunction we used hand-grip strength, 6-minute walk test, bioelectrical impedance analysis. Quality of life was evaluated using St. George's respiratory questionnaire (SGRQ). Results: Increase in the frequency of COPD exacerbations was associated with the decrease in the 6-minute walk test distance (r= -0.214, P = 0.034) and with the rise of sarcopenia according to the results of bioelectrical impedance analysis – lower fat-free mass index (r = -0.201, P = 0.047). Frequency of COPD exacerbations had a weak correlation with the degree of the activity limitation component of SGRQ (r = 0.436, P < 0.001). Conclusions: COPD exacerbation plays an important role in progression of the skeletal muscle dysfunction. It decreases endurance of the skeletal muscles, diminishing their size, which manifests itself in reduced exercise tolerance. Increase in the frequency of the COPD exacerbations also worsens all components of the life quality.

Nonadherence to treatment and quality of life among patients with chronic obstructive pulmonary disease Shorouk Mohsen, Fadia Zaki Hanafy, Aya Ahmed Fathy, Abdel-Hady El-Gilany Lung India 2019 36(3):193-198 Objectives: Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory diseases. Assessment of medication nonadherence and quality of life (QOL) is important in such chronic diseases. The aim of the study was to describe treatment nonadherence and QOL of COPD patients and their associated factors. Materials and Methods: A cross-sectional study was performed in Mansoura Chest Hospital on 133 already diagnosed inpatient cases of COPD from March to August 2017. Data were collected using two validated questionnaires, Morisky Medication Adherence Scale to assess medication adherence and St George's Respiratory Questionnaire for COPD patients (SGRQ-c) to assess QOL. Results: About 45% of studied group were nonadherent to prescribed medications. Logistic regression analysis showed that duration of disease is the only independent risk factor for nonadherence. The scores on SGRQ-c indicated sever QOL affection in COPD. SGRQ-c scores show significant impairment with the presence of comorbidities, hospital admission, and frequency of exacerbations. Conclusions: Nonadherence to treatment was affected mainly by the duration of disease. QOL impairment in COPD is influenced by broad range of factors suggesting the importance of QOL assessment in those patients. No association was found between nonadherence to treatment and QOL.

Flexible bronchoscopy-guided vocal cord biopsy under conscious sedation: An option to surgical biopsy in special situations Ravindra M Mehta, Abhinav Singla, Pavankumar Biraris, Sheelu Srinivas, Lakshmipriya Srinivasan Lung India 2019 36(3):199-201 Introduction: Vocal cord (VC) biopsies are usually performed with rigid laryngoscopy under general anesthesia (GA). In patients with comorbidities such as cardiovascular or pulmonary disease, the risk of GA is high, with morbidity and potential mortality. We describe VC biopsy (VCB) in such a high-risk cohort, done safely and successfully with flexible bronchoscopy-VCB (FB-VCB) and conscious sedation. Methods: FB-VCB was done in two groups of patients – the first at high risk for GA due to comorbidities and the second group where VC lesions were found incidentally in the course of FB done for other reasons. FB was done with local anesthesia and conscious sedation, and the VC lesion was identified. Flexible forceps were introduced through the working channel of the bronchoscope, and the lesions were carefully sampled. Results: FB-VCB was performed in 15 patients (14 males and 1 female) with a mean age of 60.7 ± 12.1 years. Of these 15 patients, 6 patients were poor candidates for GA due to comorbidities and 9 patients had incidental VC lesions found during bronchoscopy. A diagnosis was made in 14/15 (93.3%) patients. Complications included a mild ooze and hoarseness of voice for a few days, which did not require any intervention. Conclusion: We report one of the few series of patients with VC biopsies done with FB (FB-VCB) under conscious sedation, without significant complications. It is safe and useful in high-risk patients who are poor candidates for GA, with a good diagnostic yield.

A single-center experience of pediatric foreign-body aspiration: A retrospective 4-year case series Mustafa Erman Dorterler, Osman Hakan Kocaman, Tansel Gunendi, Mehmet Emin Boleken Lung India 2019 36(3):202-206 Introduction: Foreign body aspirations (FBA) in children are serious life-threatening clinical conditions that require immediate intervention. In this study, it was aimed to retrospectively investigate the demographic features, clinical diagnosis and treatment methods of children admitted to our clinic due to FBA. Materials and Methods: The study included 86 children aged <16 years, diagnosed with tracheobronchial foreign body aspiration (FBA) between January 2013 and December 2017. All patients with two-way chest radiography were examined for foreign body aspiration diagnosis. In case of suspicion of diagnosis, low-dose multi-slice chest CT was taken. In cases of FBA diagnosis, rigid bronchoscopy was performed under sevoflurane and propofol anaesthesia supported by controlled ventilation. Evaluation was made of the patient demographic characteristics, type and localization of the foreign body removed with bronchoscopy and operation-related complications. Results: The mean age of the patients with FBA diagnosis was 3.17 years and 55.8% (n = 48) of the patients were male. The most commonly aspirated foreign body was nuts (peanut and hazelnut) (70%) and the most common finding on the chest radiographs was obstructive emphysema, determined on 51% of the patients. Bronchoscopy revealed that the foreign body was in the right main bronchus and left main bronchus in 41%. Conclusion: The main treatment for FBA is prevention. However, in patients applied with bronchoscopy for FBA, controlled ventilation and appropriate general anesthesia should be generally used. Early bronchoscopic intervention with safe anesthesia and controlled ventilation support will improve the success rates in FBA cases.

Patient characteristics and outcomes of a home mechanical ventilation program in a developing country Narongkorn Saiphoklang, Apichart Kanitsap, Pitchayapa Ruchiwit, Pattarin Pirompanich, Thiti Sricharoenchai, Christopher B Cooper Lung India 2019 36(3):207-211 Background: There are limited data on home mechanical ventilation (HMV) in developing countries. This study aimed to describe the patient characteristics, feasibility, and outcomes of an HMV program at a university hospital in Thailand. Materials and Methods: Data were collected on all patients who were discharged with HMV between October 2014 and August 2015 at Thammasat University Hospital. Results: Twelve patients (eight men and four women) underwent HMV. They were aged 71.5 ± 17.6 years; mean ± standard deviation. Indications for HMV were 6 neurologic diseases (4 amyotrophic lateral sclerosis, 1 multiple system atrophy, and 1 stroke), 2 chronic obstructive pulmonary disease (COPD), 1 tracheomalacia, and 3 combined neurologic diseases and respiratory diseases (2 stroke and COPD, 1 stroke and tracheomalacia). The duration of follow-up was 799.5 ± 780.5 days. The ratio of family income to cost of HMV usage was 77.2:1 ± 5.5:1. All patients had tracheostomies. Modes of HMV were biphasic positive airway pressure (66.7%), pressure-controlled ventilation (16.7%), pressure-support ventilation (8.3%), and volume-controlled ventilation (8.3%). Complications occurred in ten patients (83.3%), including tracheobronchitis (20 events) and ventilator-associated pneumonia (12 events). Overall mortality was 41.7% (5/12 patients), including two patients who died due to ventilator-associated pneumonia. There were no instances of ventilator malfunction. Conclusions: HMV is feasible for patients with neurological diseases and COPD in a developing country. The relatively high rate of complications indicates the need for more comprehensive clinical services for chronic ventilator-dependent patients in this setting.

Endobronchial metastasis from extrathoracic malignancies: A clinicopathological study of 11 cases Monika Breta, Sudheer Arava, Karan Madan, Ashok Singh, Deepali Jain, Randeep Guleria Lung India 2019 36(3):212-215 Introduction: Endobronchial metastases are uncommon. It accounts for 2-28%. Most common tumors that metastasis to the endobronchial site are breast, renal, endometrial and colon carcinomas. They have to be identified properly because they present poor prognosis and different treatment modalities when compared to that of primary lung carcinomas. Materials and Methods: We studied a total of 11 retrospective cases of Endobronchial metastasis. Detailed clinic pathological and radiological findings were analyzed along with a detailed Immunohistochemical workup and Endobronchial findings. Results: Mean age of presentation was 55 years with female predominance (Male to female ratio was 1:1.2). Most common tumors encountered were carcinoma breast (3), colorectal carcinomas (2), renal cell carcinoma (2) followed by one each from carcinoma endometrium, cervix and thyroid. Common symptom was cough followed by dyspnea. Exophytic endobronchial growth was common with right main bronchus being the common site. Conclusion: Endobronchial metastasis occurs in various types of malignancies. It should always be differentiated from primary lung carcinomas as they carries poor prognosis and different treatment protocol when compared to that of primary lung tumors.

Pneumococcal disease burden from an Indian perspective: Need for its prevention in pulmonology practice Parvaiz A Koul, Sudhir Chaudhari, Ramesh Chokhani, D Christopher, Raja Dhar, Kumar Doshi, A Ghoshal, SK Luhadiya, Ashok Mahashur, Ravindra Mehta, Amita Nene, Md Rahman, Rajesh Swarnakar Lung India 2019 36(3):216-225 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.

Barber's neck manipulation causing bilateral diaphragmatic paralysis and type-2 respiratory failure Ashish Kumar Prakash, Anand Jaiswal, Sandeep Mittal, Poulomi Chatterjee, Sameer Kotalwar, Bornalli Datta Lung India 2019 36(3):226-228 This is a case report of an unusual cause of bilateral diaphragmatic palsy. A 54-year-old gentleman, presented to us with exertional dyspnea and chest heaviness for the past 6 months which had increased in the last 6 days. Dyspnea increased on lying down. He was diagnosed as pneumonia on the basis of X-ray and chest CT scan, received treatment for the same and responded to the therapy. However, breathlessness and hypercapnia persisted. He had unexplained hypercapnia for which extensive investigations were carried out. Neurological and cardiac assessments were essentially normal. On revisit clinical examination, he was found to have paradoxical diaphragmatic movement with respiration. Ultrasound of chest detected no diaphragmatic movement. Detailed history elicited that patient was fond of neck massage and neck cracking wherein his barber would bend his neck with jerk to either side after a haircut.After considering all possible etiologies; we concluded that it was a case of diaphragm palsy induced by barber neck manipulation, leading to Type-2 respiratory failure. The fact that the vital clues to the diagnosis were elicited by detailed history and thorough examination reinforces that history and clinical examination for doctors shall remain a very important tool for clinical diagnosis.