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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 9 | Issue 1
Page Nos. 1-128

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EDITORIAL  

Research in respiratory care p. 1
Souvik Chaudhuri, Pratibha Todur, Anitha Nileshwar
DOI:10.4103/ijrc.ijrc_66_19  
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REVIEW ARTICLES Top

Twenty-five years of excellence; respiratory therapy in India - Past, present, and future Highly accessed article p. 5
Jithin K Sreedharan, Sumi Varghese
DOI:10.4103/ijrc.ijrc_62_19  
Respiratory therapy (RT) profession in India is over 25 years old. Although there have been key advancements in the profession, no history and limited evidence are available about its development and transformation. This article provides a viewpoint on the history and development of the RT field, the evolution of RT education in India, its current state, and the way forward. It also describes in brief the establishment of professional organization, scientific journal, and other major events pertinent to the RT profession in India. This article also emphasizes the need to rationalize the sector and to shape its future to suit the needs of over a billion people who utilize the services of related facilities, directly or indirectly in a highly dynamic healthcare environment. Resolutions to address a few challenges have also been considered, which in our view could be a way forward in this profession. A comprehensive review and assessment was conducted through direct communication, personal interviews, and the review of existing documents in professional organization's archives, representative hospitals, academic institutes, and other relevant texts. The data obtained were evaluated for its relevance and grouped on a thematic basis. This is currently the first paper about the comprehensive history and development of the RT profession in India over the last 25 years.
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Acute respiratory distress syndrome in pregnancy and peripartum: Facts and figures p. 12
Nissar Shaikh, Abdulgafoor M Tharayil, Arshad H Chanda, Adel E Ahmed Ganaw, Muhammad Shakeeel Riaz, Stefan Alfred Hubertus Rohrig, Marcus Lance
DOI:10.4103/ijrc.ijrc_34_19  
Acute respiratory distress syndrome (ARDS) is a serious condition occurring rarely during pregnancy and peripartum period. ARDS occurs either due to pregnancy associated risk factors or due to the increased risk during pregnancy. Clinical presentation, arterial blood gas, chest X-ray, and computerized tomography will help in the diagnosis of ARDS. Management of ARDS in pregnancy and peripartum period can be summarized by the “ARDS12,” including lung protective ventilation (lower tidal volume, higher respiratory rate, positive end expiratory pressure titration), negative fluid balance, neuromuscular blocking agents, prone position, use of inhaled nitric oxide, high frequency oscillation ventilation, extracorporeal membrane oxygenation, extracorporeal carbon dioxide removal, use of corticosteroids and continuing the supportive care. Overall morality from ARDS is showing decreasing trends, and the mortality during pregnancy and peripartum period is significantly lower than in general population.
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Noninvasive ventilation in prehospital settings: A narrative review Highly accessed article p. 20
Mohammed D AlAhmari, Jithin K Sreedharan
DOI:10.4103/ijrc.ijrc_54_19  
The prehospital use of noninvasive ventilation (NIV) by emergency medical services is increasing. Applying NIV in the prehospital setting began to gain more attention in the late 1990s when the primary form of noninvasive positive pressure ventilation emerged as a substitute to endotracheal intubation. For the last several years, NIV has become the standard of care for acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease patients in the prehospital setting. A remarkable number of studies demonstrate a reduction in mortality and intubation rates in comparison to standard care when NIV is initiated in the prehospital setting, though there is a lack of evidence to strongly recommend the use of prehospital NIV as a first choice. An in-depth understanding of the science and technological background of NIV machines and interfaces can help attending clinicians in the prehospital setting and thus enhance therapeutic effectiveness by maximizing patient comfort, safety, and stability. Selections of the patients, devices, and interfaces, as well as achieving good patient-ventilator synchrony, are the key aspects of a successful outcome.
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Functional outcomes associated with inspiratory muscle strength training in chronic obstructive pulmonary disease subjects: Narrative review p. 26
Veena Kiran Nambiar, Savita Ravindra
DOI:10.4103/ijrc.ijrc_38_19  
In this study, the literature review focuses on the available evidence for the effects of inspiratory muscle strength training (IMST) using a threshold loading device in participants with chronic obstructive pulmonary disease (COPD). The search involved a computerized database pertaining to studies that included the outcomes of a pressure threshold IMST published after the year 2000. Sixteen articles were selected which showed outcomes relating to inspiratory muscle strength (maximal inspiratory pressure), respiratory muscle function, dyspnea, functional capacity, and health-related quality of life in COPD participants. However, the IMST protocols varied in the different studies. Most of the studies demonstrated promising and significant improvements in most of the outcomes of IMST in COPD patients; however, the effects on respiratory function remain equivocal and need to be explored further through future research.
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ORIGINAL ARTICLES Top

Prevalence of multidrug-resistant tuberculosis at a regional drug-resistant tuberculosis center of Maharashtra p. 30
Gauri Suhas Kulkarni, Supriya Dhakne Palwe, Nilesh P Patil, Abhijit J Telkhade, Jui Kadukar
DOI:10.4103/ijrc.ijrc_10_19  
Introduction: Multidrug-resistant tuberculosis (MDR-TB) has created a significant health problem in most of the countries, and it is an obstacle to effective TB control. Aims and Objectives: The study aims to study the prevalence of MDR-TB among new cases, retreatment cases and to study the rate of MDR-TB detection among suspected cases of Category I (CAT I) failure, CAT II failure and at the start of CAT II. Patients and Methods: The present retrolective study was conducted by reviewing the records of diagnosed MDR-TB patients at a drug-resistant TB center from January 2012 to December 2013. The data of new and retreatment pulmonary TB (PTB) cases diagnosed during that period were collected. The data were analyzed to find out the prevalence of MDR-TB, and the rate of MDR-TB detected among each CAT. Results: The prevalence of MDR-TB in new cases was 0.10% and that of retreatment cases was 4.3%. The rate of MDR-TB detection among suspected cases of CAT I failure was 16.8%, 52.4% in CAT II failure, 11.6% at the start of CAT II, 11.7% among sputum positive during any month follow-up, 6.6% among MDR-TB contacts. Conclusion: Timely suspicion and diagnosis of MDR-TB and treatment are important in new and retreatment cases. All relapse or defaulter patients should be screened for MDR-TB at the start of CAT II treatment. MDR-TB should be suspected in any sputum-positive TB patient during treatment/sputum positive relapse/defaulter PTB.
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Pharmacological management of chronic obstructive pulmonary disease by low-dose theophylline: A prospective hospital-based study in East Godavari of Andhra Pradesh p. 35
Bhargav Prasad Bathula, Haider Shaik, M Yasovardhan, S Kavitha Deepthi, Pandit Vinodh Bandela, P Subbarao
DOI:10.4103/ijrc.ijrc_11_19  
Background: High therapeutic dose of theophylline is not tolerated well by some patients. As it is an effective and affordable drug, the effectiveness of low-dose theophylline in pharmacological management of chronic obstructive pulmonary disease (COPD) was assessed. Aim: The aim of this study was to detect the efficacy of low-dose theophylline in COPD patients. Patients and Methods: Patients with stable COPD were enrolled. The complete blood picture (CBP), pulmonary function tests (PFTs), and St. George's Respiratory Questionnaire (SGRQ) were performed at enrolment. Patients were categorized into two groups: subjects and controls. All the participants were given medication for COPD as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. However, subjects were kept on low-dose sustained-release oral drug theophylline (150 mg twice daily) as an add-on. At every follow-up, once every 10 days up to 30 days, their parameters were recorded. The difference between the prognostic biomarkers was analyzed using the Student's “t”-test. Results: The CBP, SGRQ, and PFTs showed improvement in COPD patients treated with low-dose theophylline, i.e., subject group. Even though the PFTs improved in subjects, evidence of COPD remained. Low-dose theophylline may help to improve the quality of life in COPD patients. Conclusion: As a Cost-effective medication, low-dose theophylline can be used as an add-on drug to GOLD guidelines for the treatment of COPD. The subjects may feel better and can lead their normal life even with COPD.
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Psychometric analysis of the bengali clinical chronic obstructive pulmonary disease questionnaire p. 40
Aniruddha Banerjee, Laijun Nahar, Showket Ahmad Bhat, Ashutosha Kumar, Rachna Goenka, Pralay Sharma, Swapan Paul, Abhijit Chattopadhyay, Sk Swaif Ali, James Michael, Munmun Koley, Subhranil Saha
DOI:10.4103/ijrc.ijrc_19_19  
Background: The Clinical Chronic Obstructive Pulmonary Disease Questionnaire Bengali version (CCQ-B) is a prevalidated, patient-administered, 10-item questionnaire assessing symptom severity (SS) and quality of life in adults suffering from chronic obstructive pulmonary diseases (COPDs). To date, no validated Bengali version of the questionnaire is available. We aimed to translate it into Bengali and examine its psychometric properties. Methods: The CCQ-B was produced by standardized forward–backward translations. A cross-sectional study was conducted to gather responses by consecutive sampling. Reliability was examined using internal consistency (n = 110) and test–retest reliability (n = 30) analyses, concurrent validity by comparing with COPD Assessment Test questionnaire scores, while construct validity by exploratory principal component analysis (varimax rotation; n = 110). Subsequently, confirmatory factor analysis (CFA; n = 110) was performed to verify the model fit of the a priori identified scales. Results: The internal consistency (Cronbach's α) for overall CCQ-B was 0.746, indicating acceptable reliability. Satisfactory values of test–retest reliability and concurrent validity were found. On factor analyses, all the items loaded above the prespecified value of 0.3. Varimax rotation identified three components (SS, health and social life, and depression and limitation of activities), explaining 58.2% of variation. The Kaiser–Meyer–Olkin was 0.734 and Bartlett's test of sphericity was also significant. Goodness-of-fit of the three-component model in CFA was mediocre, but acceptable. Conclusion: The CCQ-B, consisting of 10 items and framed within three components, is a valid and reliable questionnaire but measured different dimensions from the English version.
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Use of risk calculator in predicting postoperative respiratory failure in patients undergoing elective/emergency surgery at a tertiary care hospital in South India p. 47
Surendran Aneeshkumar, Lakshmikanthan Sundararajan
DOI:10.4103/ijrc.ijrc_25_19  
Background and Objective: Post-operative respiratory failure (PRF) is one of the serious and common complications associated with poor outcomes, prolonged hospital stay and increased health care expenditure. Objective identification of factors leading to PRF would help optimization of patients and improve outcomes. The aim of the study was to assess the risk of PRF in a cohort of patients undergoing surgery using a validated risk calculator score. Methods: The risk calculator score developed by H Gupta et al was used to predict the chances of PRF in patients undergoing elective/emergency surgery at our hospital from January to June 2016. The primary end point was discharge from hospital or death. Results: 100 patients (Male: 74; Female: 26) undergoing elective/emergency surgery were analyzed. Four patients (4%) died and eleven (11%) developed respiratory failure. A receiver operating characteristic (ROC) curve with a risk calculator score of 6.30 had 92% sensitivity and 82% specificity for predicting PRF. A higher risk score had good correlation with longer hospital stay ( p=0.001). Interpretation and Conclusion: PRF risk calculator score is a valuable tool in predicting respiratory failure in patients, undergoing elective/emergency surgery. It can be useful in identifying high risk patients, allowing one to make an informed choice prior to surgery and may also help optimise such patients pre-operatively.
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A retrospective analysis of the presentation, outcomes and determinants of severity of postoperative pneumonia in upper abdominal oncological surgeries p. 52
Prasanna Vani Vanamail, Radhika Dash, Kalpana Balakrishnan
DOI:10.4103/ijrc.ijrc_21_19  
Context: Postoperative pneumonia (POP) is a major cause of morbidity following upper abdominal oncological surgeries. Aims: To estimate the incidence of POP following upper abdominal oncological surgeries and to identify its clinical and microbiologic features and the risk factors for the development of severe pneumonia. Settings and Design: Retrospective analysis of patients with POP at a regional cancer center. Patients and Methods: Patients' preoperative and intraoperative details and data on clinical and radiological features and pathogens isolated were collected. Patients with severe pneumonia were identified on the basis of Infectious Disease Society of America/American Thoracic Society criteria and their predictors were estimated. The types of respiratory support required and their outcomes were analysed. Statistical Analysis Used: Parametric Student's t-independent test was used to compare two groups' means. Categorical data are presented as frequency and percentage values. P < 0.05 was considered statistically significant. Results: Incidence of POP was 15.24% with 48% developing severe pneumonia. There was a significant difference in the mean age (59.5 ± 8.62 vs. 50.15 ± 10.53 years, P = 0.024), duration of surgery (315.77 ± 107.29 vs. 432.92 ± 177.18 min, P = 0.055), blood loss (446.15 ± 260.18 ml vs. 712.5 ± 326.22 ml), time to empiric antibiotic (15.69 ± 5.77 vs. 42 ± 38.12 h, P = 0.022), and symptom resolution ≥3 days (23.1% vs. 72.7%) between patients with nonsevere and severe pneumonia. Patients presenting with cough (odds ratio = 0.06, 95% confidence interval: 0.006–0.618) were more likely to have nonsevere pneumonia. Conclusions: Predictors of severe pneumonia are elderly, prolonged surgical duration, higher blood loss, delayed empiric antibiotic and delayed symptom resolution.
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Assessment of adherence to international standards for tuberculosis care among private practitioners of Delhi p. 58
Rashmi Agarwalla, Asna Jamal, Ekta Gupta, Rambha Pathak, Meely Panda, Faheem Ahmed
DOI:10.4103/ijrc.ijrc_23_19  
Context: Tuberculosis (TB) is among the top ten causes of mortality, and to control this growing burden of disease, it is imperative that all TB patients receive the same quality of care, based on the best evidence available. The best practices for TB as enshrined in the International Standards of TB Care (ISTC) if adhered to can expedite the efforts to control TB. Aims: The aim of the study was to evaluate the current practices for diagnosis and treatment of TB among the private medical practitioners against benchmark practices in ISTC and to assess the factors associated with adherence to ISTC. Subjects and Methods: A cross-sectional study was conducted among fifty private practitioners (PPs) of Delhi over a period of 3 months. Data collection was done using a structured pro forma, and interviews were conducted privately in the PPs' office. The key outcome variable was the proportion of practitioners adhering to the ISTC standards of diagnosis (standards: 1–6) and treatment (standards: 7–13). Results: Among fifty practitioners, 42% were found to be adherent, while 58% were found to be non-adherent. Significant association was found between gender and any form of training/sensitization received in the Revised National Tuberculosis Control Program (RNTCP) (P < 0.05). Conclusion: As the adherence to the ISTC care among the PPs was poor, there is a need to train and give incentives to participating PPs in timely and regulated way. PPs play a key role in diagnosing and treating TB patients, and hence, timely training and orientation in RNTCP and standard treatment for TB care are essential and should be key priority areas.
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Clinicoradiological and cardiac profile of pulmonary artery hypertension in treated patients of pulmonary tuberculosis in a tertiary center p. 62
Achal B Parekh, Anand K Patel, Mayur H Adalja
DOI:10.4103/ijrc.ijrc_26_19  
Introduction: Tuberculosis (TB) is a global health burden. Pulmonary TB (PTB) can cause important thoracic sequelae involving the lungs, airways, vessels, mediastinum, pleura, and chest wall. Pulmonary hypertension (PAH) is a serious respiratory disability occurring from structural lung damage and chronic hypoxia. Aims and Objectives: The aim of this study is to evaluate the clinical, radiological, and echocardiographic profile of PAH in patients treated for PTB and how they correlate with each other. Patients and Methods: This was a cross-sectional study. A total of 100 patients with PAH with a history of PTB were analyzed. Chest X-ray, electrocardiogram (ECG), and two-dimensional-echocardiography were obtained in all of them. Detailed clinical and radiological profile of those having PAH was noted. The usefulness of echocardiography for diagnosing cor pulmonale was studied. Results: We investigated 75 males and 25 females. Cough was the most common presenting symptom. The mean time since the treatment of PTB was 7.5 years. The most common radiological abnormality, fibrocavitation was found in 25% of the patients, whereas P-pulmonale was the most common finding on ECG. Majority of the patients had moderate PAH with a pulmonary arterial systolic pressure 50–65 mmHg. There was a significant relationship between PAH and tricuspid regurgitation (TR) (P < 0.05). No statistical association was seen between the right ventricle internal diameter at end-diastole and TR and PAH. No relationship was seen between years of treatment completed for PTB and PAH. Conclusion: Treated patients of PTB presented with different grades of PAH on an average of 7 years after therapy. Hence, early diagnosis, treatment, and long-term follow-up of PTB are of foremost importance to prevent posttubercular complications and respiratory disability.
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Efficacy of auto-PAP titration in obstructive sleep apnea: Single-center experience p. 68
Amrutha S Unnithan, G Gokul Krishna, P Hari Lakshmanan
DOI:10.4103/ijrc.ijrc_35_19  
Background: Obstructive sleep apnea (OSA) is a sleep-associated breathing disorder, which left untreated can cause severe morbidities or even mortality. The recommended treatment strategy for moderate-to-severe OSA is continuous positive airway pressure (CPAP). The optimal pressure required for OSA can be measured by either manual CPAP titration or auto-CPAP titration study. Objective: To assess the efficacy of auto-PAP titration for OSA patients. Methodology: This was a cross-sectional study conducted on Pulmonary Medicine Sleep Lab at Amrita Institute of Medical Sciences, Kochi. Fifty patients who have undergone full-night polysomnography and followed with auto-PAP titration are included in the study. The research was approved by the institutional ethics committee. Results: In the study cohort, 50% showed optimal titration, 40% good titration, 10% adequate titration and none in unacceptable category. The results showed that auto-PAP usage has good result in moderate-to-severe OSA. Conclusion: Unattended auto-PAP titration seems to be highly effective modality which can be considered as an alternative to attended CPAP titration, thus reducing labor intensiveness and cost.
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Association of metabolic syndrome in obstructive sleep apnea patients: An experience from zonal tertiary care hospital in Eastern India p. 71
Santosh Kumar Singh, Ajai Kumar Tentu, Sarvinder Singh, Nidhi Singh, Chinmaya Dash, Vani Singh, Rongala Laxmivandana, Rachana Warrier
DOI:10.4103/ijrc.ijrc_36_19  
Introduction: Even in a tertiary health-care setting, obstructive sleep apnea (OSA) patients often remain underdiagnosed. OSA and metabolic syndrome (MS) share many essential cardiovascular risk factors, including obesity, hypertension, and insulin resistance. Despite numerous studies, the relationship between OSA and MS still remains debatable. Aim: The purpose of our study was to see how frequently MS occurred in OSA patients and also if the presence of MS had any correlation with age, sex, or severity of OSA. Methodology: This cross-sectional study included 50 OSA patients being evaluated on outpatient department basis. All the patients were screened with detailed history; examination; hematological, biochemical parameters; and polysomnography. Results: In this study, out of 50 OSA patients, 41 were male and 9 were female; with age, body mass index (BMI), Apnea–Hypopnea Index (AHI), neck circumference, and waist circumference having mean of 42.5 years, 27.028 kg/m2, 33.49/h, 39.7 cm, and 37.23 inch, respectively. Out of 28 obese patients, 22 had AHI >30 and 6 had AHI <30. 31 (62%) OSA patients were found to have MS, of which 27 were male and 4 were female. Pearson's bivariate correlation has also shown statistically significant association between AHI score and BMI value (P = 0.01). Conclusion: Our study has shown a positive association between OSA and MS and OSA may represent an important risk factor for development of MS. Therefore, it is prudent for clinicians to systematically evaluate the presence of metabolic abnormalities in OSA patients and vice versa.
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Effective counseling: A major challenge of tuberculosis control programme in tackling the dual disease burden of tobacco consumption among tuberculosis Patients in India p. 77
Nehal , Shyamala Krishnaswamy Kothandapani, Bidhata Khatri, Supriya Tiwari
DOI:10.4103/ijrc.ijrc_39_19  
Background: Tuberculosis (TB) and tobacco are the major public health problems with high morbidity and mortality. Tobacco consumption is the most common modifiable risk factor associated with TB infection, relapse, and recurrence. This study aimed at estimating the prevalence of tobacco consumption patterns among patients with TB and assessing effectiveness of counseling and tobacco cessation intervention. Patients and Methods: A cross-sectional prospective study was conducted in patients with TB (pulmonary and extrapulmonary), ≥18 years registered under Revised National TB Control Program (RNTCP) (Directly Observed Treatment, Short-course), at a tertiary care hospital, South India, from January 2018 to June 2018. Relevant clinical data was collected. Participants were interviewed about tobacco consumption, and counseling was offered to these patients and willingness to quit tobacco usage was assessed using 5A and 5R's approach. Results: Of the total 125 patients, 40 of them were tobacco users (smoking and oral tobacco) with a prevalence of 32%. Mean age was 38 ± 2 years. Tobacco consumption was significantly high (19.2%) in the 31–50 years age group (P = 0.04) with an increased association among pulmonary TB. Majority of the tobacco users were male (38.96%), predominantly smokers (31.16%) and female patients were oral tobacco users (20.83%). With effective counseling, 60% of tobacco users were willing to quit tobacco gradually, while 27.5% were willing to quit abruptly and avail pharmacotherapy. Conclusion: There is high prevalence of tobacco usage among TB patients. Majority of males were smokers. Females were predominantly oral tobacco users. Implementing strategies for effective counseling and tobacco cessation intervention, in coordination with RNTCP would have greater impact on treatment outcome.
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Cognitive impairment and its effect on chronic obstructive pulmonary disease: An underestimated phenomenon p. 82
Sachin L Patel, Jagdish R Varma, Jaishree D Ganjiwale, Nimit V Khara, Ravish M Kshatriya, Rajiv P Paliwal, Sateesh N Patel
DOI:10.4103/ijrc.ijrc_45_19  
Background: To assess the ability of the Rowland Universal Dementia Assessment Scale (RUDAS) to predict inhaler technique and determine the prevalence of cognitive impairment in chronic obstructive pulmonary disease (COPD). Patients and Methods: This cross-sectional study included 98 participants, and we recorded age, education, locality, occupation, COPD stage, comorbidities, duration of inhaler use, and smoking history. Inhaler technique was assessed using an internationally accepted schedule (nine steps). RUDAS, a multicultural cognitive assessment scale, was used to assess cognitive function. Results: The study included 92 males and 6 females with the mean age of 63.9 years. At a cutoff of 24, RUDAS had 93.6% sensitivity and 88.2% specificity in screening incorrect inhaler technique. Those having a RUDAS score <24 were 272 times more likely to perform incorrect inhaler technique. On comparison of incorrect and correct inhaler technique groups on various parameters in univariate analysis, it was found that the groups were significantly different in terms of education, locality, occupation, COPD stage, comorbidities, and smoking history. However, in logistic regression, only RUDAS score <24 was found to be a predictor of incorrect inhaler technique. At the original cutoff of 23, RUDAS screened 42.9% (n = 42) of the patients as having cognitive impairment. Conclusions: High prevalence of cognitive impairment among COPD patients and its untoward impact on inhaler technique is an important but underestimated clinical issue. RUDAS is an effective tool to predict incorrect inhaler technique and cognitive impairment in COPD.
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Baseline Vitamin D as a predictor of mortality among hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease in an endemically Vitamin D-deficient area in North India p. 88
Mohammad Ramzan Bhat, Shabir Ahmad Dar, Mir Waseem, Mir Nadeem
DOI:10.4103/ijrc.ijrc_48_19  
Background: Conflicting data suggest that Vitamin D reduces the risk of developing chronic obstructive pulmonary disease (COPD) and COPD exacerbations. Scant data are available regarding the Vitamin D status in patients with COPD in India where Vitamin D deficiency is rampant. Objectives: We set out to study the role of baseline Vitamin D on the outcome of acute exacerbation of COPD (AECOPD) in terms of exacerbations, hospitalizations, and mortality. Materials and Methods: In a prospective observational design, 147 consenting participants with AECOPD were recruited and serum Vitamin D assessed at admission. The patients were followed for 3 months for treatment outcomes in terms of mortality, readmissions and exacerbations. Standard statistical methods were used to compare the results among those with sufficient and insufficient Vitamin D status at baseline. Results: Out of 147 completely followed participants, 113 (76.9%) were deficient in Vitamin D (mean ± standard deviation = 11.79 ± 8.5 [normal 30–100 ng/ml]). Patients with low Vitamin D were found to have a significantly higher 90-day mortality than those with normal Vitamin D status (P = 0.42; hazard ratio 4.8, P = 0.032). No statistically significant differences were observed in rates of exacerbations or hospital admission. Conclusion: Patients of AECOPD having baseline Vitamin D deficiency at admission have a higher mortality than those with normal Vitamin D level. Thus, Vitamin D level can serve as a prognostic indicator of the outcome of AECOPD. Larger studies are suggested to further study the association and also determine any role of Vitamin D in the treatment of such cases.
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CASE REPORTS Top

Bilateral pulmonary embolism presenting as lung abscess in a tuberculosis patient: A rare presentation p. 94
Naveen Kuzhikkattil, Anil Saxena, Suman Khangarot, Shinu Abdul Wahab
DOI:10.4103/ijrc.ijrc_5_19  
Pulmonary embolism is a life-threatening medical emergency associated with high mortality and morbidity which is likely to be missed if a high index of suspicion is not maintained. Classical triad of chest pain, dyspnea, and hemoptysis is seen only in a minority of cases. Both inherited and acquired conditions are involved in its etiology. A case of bilateral pulmonary embolism presenting as lung abscess in a 65-year-old female with active tuberculosis is being discussed here.
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Large cell neuroendocrine tumor of the lung: A diagnostic challenge p. 97
Jayasri Helen Gali, Harsha Vardhana Varma
DOI:10.4103/ijrc.ijrc_7_19  
Lung neuroendocrine carcinoma (NEC) is a rare heterogeneous carcinoma with NE cells in the pulmonary and bronchial epithelium as the site of origin. We describe a case of large cell NEC (LCNEC) in a 55-year-old male, smoker with 25 pack-years, who presented with cough, dyspnea, hemoptysis, and loss of appetite for 6 months. There was no diabetes, hypertension, asthma, chronic obstructive pulmonary disease, tuberculosis, or contact with tuberculosis or malignancy. The presence of a large homogenous mass lesion in the right chest on chest X-ray, further clearly defined on chest computed tomography scan (130/94/123 mm) was suggestive of huge mass. There was no mediastinal or pleural involvement. Possibility of LCNEC was suspected as the ultrasound-guided biopsy was indicating the presence of poorly differentiated carcinoma. Immunohistochemistry was negative for thyroid transcription factor, cytokeratin 7 but was positive for synaptophysin and P40, suggestive of high-grade LCNECs. It was in T4N0M0, stage 3A and treatment with combination chemotherapy was initiated.
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Primary liposarcoma of lung - A rare case report p. 100
Amisha Gami, Nisha Khanna, Shailee Mehta, Dhaval Jetly
DOI:10.4103/ijrc.ijrc_12_19  
Liposarcoma of the lung is an extremely rare disease, with very few cases reported to date. We report a case of a primary pulmonary liposarcoma with pleural involvement in a 36-year-old male with peribronchial lymph node metastasis. Thoracotomic excision revealed a well-differentiated liposarcoma. Liposarcoma of lung is a rare tumor, which needs to be considered while looking at a biopsy, especially because it has a good survival when adequately excised. Lymph node metastasis, though rare can also occur.
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Birt–Hogg–Dubé syndrome p. 103
Abdulmonam Ali, Naga Srinivas Sirikonda
DOI:10.4103/ijrc.ijrc_14_19  
Cystic lung diseases have a broad differential diagnosis. Accurate diagnosis can make a significant difference in the management approach, as it is highly disease specific. Unique imaging and clinical features can provide crucial clues that help clinicians distinguish various etiologies. Birth-Hogg-Dubé syndrome is a cystic lung disease with extra pulmonary manifestations. Managements involves solid organ cancer screening and hence accurate diagnosis is vital.
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Bronchopleural fistula closure with vascular plug and intrapleural glue administration p. 106
Neeraj Sharma, Vasu Vardhan, Chandan Singh Katoch, Aseem Yadav
DOI:10.4103/ijrc.ijrc_17_19  
The presence of communication between a mainstem, lobar, or segmental bronchus and the pleural place is called a bronchopleural fistula (BPF). It is commonly caused as a result of postoperative complication of lung resection surgeries, chemotherapy or radiotherapy for lung cancer, persistent spontaneous pneumothorax, empyema, lung abscess, and tuberculosis. A 20-year-old male underwent decortication for diffuse right-sided tuberculous pleural thickening. Postsurgery, he developed BPF. He underwent open thoracic surgery for BPF closure. However, he continued to have air leak and persistent empyema. Repeat evaluation revealed a large BPF at the anterior segment of the right upper lobe on computed tomography chest, which was confirmed on bronchoscopy. He underwent bronchoscopic closure (under fluoroscopic guidance) of BPF with a 6 mm × 7 mm vascular plug successfully. Major air leak stopped and lung expansion increased on chest X-ray. However, small air leaks (alveolar-pleural fistula) persisted. Later, he was subjected to intrapleural diluted fibrin glue administration (fibrinogen + aprotinin + thrombin) via a chest tube at bedside. Application of diluted fibrin glue through the chest tube succeeded in completely sealing the small air leaks. Radiologically, there was no further lung collapse and the pleural space was nearly obliterated.
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Paraquat poisoning presenting as the “Daisley Barton syndrome” p. 110
Souvik Chaudhuri, Maddani Shanmukhappa Sagar, Sunil Ravindranath, Vinod Reddy
DOI:10.4103/ijrc.ijrc_47_19  
Paraquat is a bipyridilium herbicide which is highly toxic. Due to its corrosive effects, it can lead to esophagitis, esophageal rupture, and gastritis. It leads to the formation of reactive oxygen species which causes multiorgan damage, prominent among those being pulmonary, renal, and liver dysfunction. One of the rare causes of respiratory distress after paraquat poisoning is spontaneous pneumothorax due to pneumocyte injury, also known as the “Daisley Barton Syndrome.” We report a case of paraquat poisoning who developed alveolitis initially and later had bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and the patient recovered initially but later deterorated due to other complications. We should be aware of this phenomenon, and sudden worsening of the respiratory parameters should alert the clinician for prompt treatment.
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Postoperative pneumomediastinum with bilateral pneumothorax following percutaneous nephrolithotomy p. 113
Deepak Dwivedi, Saurabh Sud, Shalendra Singh, Mohit Kumar
DOI:10.4103/ijrc.ijrc_32_19  
Postoperative pulmonary complications are uncommon following percutaneous nephrolithotomy (PCNL). However, evidence has shown the occurrence of pneumothorax and pneumomediastinum following PCNL. Such life-threatening complications can prove catastrophic if not diagnosed and intervened immediately. Perioperative point-of-care lung ultrasound can play a pivotal role in immediate diagnosis of the pneumothorax and resultant timely intervention limits the morbidity in the immediate postoperative period.
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Noninvasive ventilation influenced the survival of extreme super-super obese with obesity hypoventilation syndrome Highly accessed article p. 116
Mohammed Nasser Alwadai, Awad Alqahtani, Omprakash Palanivel
DOI:10.4103/ijrc.ijrc_33_19  
Recent studies conclude noninvasive ventilation (NIV) as a standard first-line therapy for any respiratory failure. The efficacy of NIV in obesity is well defined. In this context, the effectiveness of NIV in extreme super-super obese patients with obesity hypoventilation syndrome is not well studied, and the usage of NIV is controversial because of rare incidence. However, identifying the right patient, right timing, right clinical expertise, correct positions, and right appropriate NIV settings can produce positive results. Therefore, we present a unique case of a 32-year-old male weighing 283 kg, with body mass index >92 kg/m2 and carbon dioxide retention, whose symptoms were worsening despite adequate conventional treatment. He received continuous NIV for 70 h using a standard protocol with close monitoring. There was improvement in the patient vitals and medical condition with significant reduction in arterial carbon dioxide tension, leading to reduction in the length of intensive care unit stay and prevention of further complications. Long-term research is encouraged to validate NIV effectiveness in this group of patients.
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Airway pressure release ventilation benefits in a patient with chronic lymphocytic leukemia p. 120
Oluwasegun Albert, Abdulraheem Alzahrani, Abdullah Almutairi
DOI:10.4103/ijrc.ijrc_53_19  
Background: Airway pressure release ventilation (APRV) is a novel mode of mechanical ventilation (MV) used in the treatment of acute respiratory distress syndrome (ARDS) for patients with severe hypoxemia with a strategy to prevent ventilator-induced lung injury (VILI). APRV can avert VILI because it can limit alveolar-distending pressures. This is a case report of a 45-year-old man diagnosed with chronic lymphocytic leukemia who later developed community-acquired pneumonia and ARDS. Methods: APRV was applied successfully. Initially, he was unsuccessfully managed on conventional ventilation using an “open-lung” ventilation strategy (high positive end-expiratory pressure, high respiratory rate, and low tidal volume), recruitment maneuvers, and prone positioning. Results: A change in the ventilation mode to APRV resulted in the reduction of extravascular lung water as indicated by a chest X-ray, improvement in the oxygenation indices, and successful liberation from the ventilator. Conclusion: This case report concluded that APRV is safe in patients diagnosed with ARDS if other “open-lung” MV approaches and prone positioning have failed.
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The utility of spirometry in assessment of presumptive diagnosis of bronchial asthma in a Nigerian tertiary hospital p. 126
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/ijrc.ijrc_31_19  
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Electric shock-induced pulmonary hemorrhage – A rare phenomenon p. 127
Sourya Acharya, Babaji Ghewade, Samarth Shukla, Maria Prothasis
DOI:10.4103/ijrc.ijrc_49_19  
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