Acute respiratory distress syndrome (ARDS) is considered a frequent and serious lung disease that is continuously linked with an increase in both morbidity and mortality. Mechanical ventilation (MV) is considered as the gold standard therapy in the management of ARDS; although MV support is lifesaving, it is also associated with potentially harmful threats such as ventilator-induced lung injury (VILI). It is understood from the physiological background itself that VILI has a considerable impact on the prognosis of a patient. Therefore, the current studies show that focusing on key therapeutic elements causing over-distension of the available lung units is more imperative for indicating further damage than how much pressure is used to ventilate. In the past two decades, there has been an increasing trend toward using driving pressure (DP) in the management of ARDS patients in intensive care units (ICUs). Recent studies propose that measuring DP in ARDS patients, in addition to the other respiratory mechanics measurements, may support selecting and customizing appropriate ventilator parameters, which, in turn, improves patient outcomes and decreases mortality rate. Therefore, this review is intended to outline the physiological meaning of DP, the clinical measurement and application of DP and factors limiting DP. Furthermore, measuring DP in non-ARDS patients and recent clinical evidence for the use of DP in the ICUs will be discussed in detail.

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“Shock” is a term that is used to signify inadequate tissue perfusion and cellular oxygenation. The basic principle of treating shock is restoring tissue perfusion and adequate cellular oxygenation. Resuscitation from shock is achieved using a combination of fluid therapy, inotropes, and vasopressors. Refractory shock has been defined as requirement of noradrenaline infusion of >0.5 μg/kg/min despite adequate volume resuscitation. Inability to use oxygen damages the cellular machinery and if not restored in time, shock can become irreversible. Mortality in these patients is very high, and the assessment and management of these patients requires a much more aggressive approach for survival. This article will focus on the management of refractory shock.

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Montelukast is one of the commonly used drugs in asthma patients. It is prescribed along with inhalational corticosteroids. Although a relatively safe drug, there is a probability of occurrence of skin rashes and skin bruising. Authors present a case report of a 64-year-old chronic asthmatic woman, reporting widespread erythematous eruptions with mild skin bruising and generalized pruritus mostly affecting her lower abdomen and upper extremities. The rash appeared 28 days after introduction of montelukast (10 mg OD). The physician excluded other attributable factors such as trauma, autoimmune disorders such as Churg-Strauss syndrome, and food allergy. Reappearance of rashes after montelukast introduction and complete resolution of the skin rashes after discontinuing it confirms montelukast as offending drug. Naranjo causality assessment score also revealed a “certain/definite” relationship to the montelukast. Long-term safety of montelukast needs to be reviewed by prescribing physicians to prevent adverse reaction.

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Exercise training in chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD) is an essential component of pulmonary rehabilitation, but physical activity for maintenance of benefits in COPD after outpatient/inpatient rehabilitation is a neglected one. The dosage of walking is not “prescribed” properly by health-care providers for maintenance of muscle mass and improving quality of life. If the ground or treadmill walking is appropriately dosed and prescribed based on 6-min walk test (6MWT), the unsupervised ground walking may be a useful alternative to supervised aerobic fitness programs for achieving fitness benefits. This article provides an overview of dosing and measuring the walking program (either ground or treadmill) objectively to novice therapists and primary care physicians based on the 6MWT to COPD patients.

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Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) result in increased morbidity, mortality and tremendous socioeconomic burden. Predicting inhospital mortality may aid prognostication, planning for the site of care, i.e., ward versus intensive care units, and better individualization of treatment. Aim of Study: This study aims in predicting inhospital mortality in patients of AECOPD based on the parameters measured at the time of admission. Methods: Known COPD patients in acute exacerbations admitted in a tertiary care hospital were interrogated for clinical history and examination. All relevant laboratory tests including arterial blood gas analysis, complete blood count, liver and renal function tests, and random blood sugar were done. Based on outcome, patients were grouped into survivors and nonsurvivors. Parameters recorded were then subjected for univariate analysis to get their statistical significance. All significant variables on univariate analysis were then analyzed further with multivariate analysis. Results: Out of the total 140 patients included in the study, 24 (17%) died during their hospital stay. Of the various acute-phase parameters recorded at the time of the admission, only five qualified to be predictors of inhospital mortality based on univariate and multivariate analyses. These were partial pressure of carbon dioxide in arterial blood (PaCO₂) (odds ratio [OR], 95% confidence interval [CI] =1.067, 0.993–1.146), pH (OR, 95% CI = 0.001, 0.001–0.584), serum glutamic pyruvate transaminase (SGPT) (OR, 95% CI = 1.032, 1.006–1.059), sodium (OR, 95% CI = 0.779, 0.689–0.881), and random blood sugar (OR, 95% CI = 1.018, 1.007–1.029). With these five factors combined, area under receiver operating characteristic (ROC) curve was 0.9684, sensitivity 79.18%, specificity 96.55%, positive predictive value 82.61%, negative predictive value 95.73%, and correctly classify acute exacerbation in 93.57%. Good survival can be expected if these parameters are within normal limits. Conclusion: pH, PaCO₂, SGPT, serum sodium, and random blood sugar at the time of admission are independent predictors of mortality in patients of AECOPD. These can be helpful in developing a prediction tool of inhospital mortality in such patients.

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Introduction: Respiratory muscle dysfunction is a cardinal feature in chronic obstructive pulmonary disease (COPD) contributing to decreased exercise capacity and pulmonary function test (PFT) limitation with progression of the disease. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) are reliable parameters for assessing the respiratory muscle strength. Aims: This study aims to measure maximal inspiratory and expiratory pressures in male COPD patients, to determine their correlates, and to study the relationship between the severity of COPD and respiratory muscle strength. Patients and Methods: This was an observational, cross-sectional study. A total of 100 males, who were known COPD patients and who were clinically stable, were recruited. Both inpatients and outpatients were studied. Spirometric PFT test was done, and MIP and MEP were measured using respiratory pressure meter. Descriptive statistics and Pearson's correlation were used. Results: The mean (± standard deviation) MIP and MEP were 47.73 (±19.6) cm H₂O and 60.76 (±11.6) cm H₂O, respectively. MIP and MEP showed a highly significant correlation (P < 0.001) with forced expiratory volume at 1 s (FEV₁) and forced vital capacity. The correlation of MIP and MEP with FEV₁shows a positive linear trend, and the MEP values were higher than MIP values. There was a decrease in MIP and MEP with increasing severity of COPD. Conclusion: MIP decreases with progression of the disease, and thus, inspiratory muscle training should be included in a pulmonary rehabilitation program.

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Background: After the 2009 pandemic, a re-emergence of hemagglutinin type 1 and neuraminidase type 1 (H1N1) influenza cases has been noted in India recently. The number of swab-positive cases has increased in the year 2017 compared to yesteryears. Since the current circulating strain (A/Michigan/7/2009 [H1N1] pdm09) is different from previous pandemic strains, a look into the clinical profile is imperative. Aims: The aim is to study the clinical, biochemical, and radiological profile of H1N1 patients at initial presentation and its influence on the mode of treatment and outcome. Patients and Methods: A cross-sectional record-based analysis of all confirmed cases of H1N1 influenza admitted at Lourdes Hospital, Kochi, Kerala, between 2015 and 2017. Confirmation of cases was done by reverse transcriptase polymerase chain reaction of respiratory specimens at Manipal Centre for Virus Research. Results: A total of 76 confirmed cases of H1N1 influenza were detected during the study period of which 36 required Intensive Care Unit admission. Most patients were between 51 and 60 years (25%). The predominant presenting symptoms were fever (98.7%), dry cough (61.8%), breathlessness (53.9%), and the most common auscultatory finding being bilateral crepitations (64.47%). Around 32.89% of cases presented with bilateral lung infiltrates on X-ray. Sixty-nine of 76 patients (90.79%) survived the disease. Conclusions: Vaccination, early recognition of the disease, and prompt initiation of treatment seem to be the only way to reduce H1N1 disease progression and associated mortality. Patients with risk factors require additional attention as clinical course can be unpredictable. Pregnancy is associated with higher rate of complications. Early respiratory support helped in preventing progression to respiratory failure in most of our patients.

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Multiple myeloma is a malignant proliferation of the plasma cells mainly affecting bone marrow, but other organs may also be involved. Multiple myeloma is rarely associated with lung plasmacytoma. Patients with extramedullary plasmacytomas have coexistent multiple myeloma in only 5% of cases. The incidence of malignant pleural effusion in multiple myeloma is very low and is approximately 1%. In this case series, we report three patients with multiple myeloma, who presented with different thoracic manifestations such as left-sided myelomatous pleural effusion, posterior mediastinal mass with central airway obstruction, and pulmonary consolidation.

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Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Lung hyperinflation or air trapping is the hallmark of COPD and the primary cause of dyspnea, poor quality of life, and advertent disease prognosis associated with the disease. Debates continue to rise against the use of forced expiratory volume 1 as the single-main evaluative parameter for patients with COPD. Inspiratory capacity (IC) together with spirometry on the other hand has been shown to be a dependable parameter that can indicate the presence and management of lung hyperinflation. Patients and Methods: This cross-sectional study included fifty patients of COPD presenting to the department of respiratory medicine. All patients underwent spirometry and 6-min walk test (6MWT). They were grouped according to the GOLD guidelines for airflow limitation, body mass index (BMI), 6MWT, BODE index, number of exacerbations (NoEs), COPD “ABCD” assessment tool, and IC. t-test and one-way analysis of variance were applied. Results: There were 37 males and 13 females. A positive correlation was found between IC and 6MWT and BMI (coefficient of 0.678 and 0.149, respectively). There was a negative correlation between IC and NoEs and BODE index (coefficient of − 0.257 and − 0.631, respectively). IC correlated strongly with the GOLD classification for airflow limitation and combined assessment of COPD. A statistically significant difference between pre- and post-IC values showed IC as the predictor of lung hyperinflation. Conclusion: IC can be used along with 6MWT, BMI, BODE index and NoE for the prognostication and management of COPD.

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Introduction: Mortality attributable to chronic obstructive pulmonary disease (COPD) in India is estimated to be among the highest in the world. Although identification and management of symptoms and signs of chronic lung diseases have improved, the psychosocial burden is often unrecognized and neglected. Psychological distress increases dependence on others, causes less effective self-management and longer hospital stays, and is known to greatly influence the disease progression. Aim: The aim of this study is to assess the degree of helplessness among COPD patients and establish its correlation with sociodemographic factors and disease severity. Subjects and Methods: This was a cross-sectional study carried out in a secondary care hospital of Delhi. A predesigned, pretested COPD Helplessness Index (CHI) questionnaire was administered to 224 participants aged 40 years or above, after obtaining informed consent. Global Initiative for Chronic Obstructive Lung Disease staging system for COPD was used to categorize patients according to their disease severity. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 17.0. Moreover, P < 0.05 was considered significant. Results: CHI was found to be directly related with COPD severity (P < 0.001). Elderly patients, males, illiterates, and smokers were found to have a higher CHI score showing helplessness in study participants. Conclusions: There is a strong correlation between helplessness and pulmonary function with age, gender, literacy, and smoking status having a significant influence on the psychological state of COPD patients. An integrated effort on the part of the patients, doctors, and the society is required to reduce the burden of COPD.

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Pleural effusions due to pancreatitis are more common on the left side, but right-sided pleural effusion is very rare. This case report describes a young male who presented with features of right-sided massive pleural effusion. Magnetic resonance cholangiopancreatography showed, chronic pancreatitis with pseudocyst extending into the mediastinum through esophageal hiatus and communicating with right pleural cavity (pancreaticopleural fistula). The patient improved clinically after placing an intercostal drainage tube and stenting of the main pancreatic duct. A clinician should consider pancreatic pathology also in the differential diagnosis of right-sided pleural effusion, even in the absence of abdominal symptoms and risk factors for pancreatitis, when initial evaluation is inconclusive.

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