Background: Novel coronavirus (SARS-CoV-2) infection is associated with hypoxemic respiratory failure. Mechanical ventilation (MV) is reported to have high mortality in SARS-CoV-2 acute respiratory ...distress syndrome. We aimed to investigate whether awake prone positioning (PP) can improve oxygenation and prevent intubation when employed early. Methods: This prospective interventional study included proven coronavirus disease 2019 (COVID-19) patients with room air saturation 93% or less. The primary outcome was the rate of intubation between the two groups. The secondary outcomes included ROX index (SpO2/FiO2%/respiratory rate, breaths/min) at 30 min following the intervention, ROX index at 12 h, time to recovery of hypoxemia, and mortality. Results: A total of 45 subjects were included (30 cases and 15 controls) with a mean (standard deviation SD) age of 53.1 (11.0) years. The age, comorbidities, and baseline ROX index were similar between the two groups. The median duration of PP achieved was 7.5 h on the 1st day. The need for MV was higher in the control group (5/15; 33.3%) versus prone group (2/30; 6.7%). At 30 min, there was a statistically significant improvement in the mean (SD) ROX index of cases compared with that of the controls (10.7 3.8 vs. 6.7 2.6, P < 0.001). No significant adverse effects related to intervention were noted. Conclusion: Awake PP is associated with significant improvement in oxygenation and may reduce the need for MV in subjects with COVID-19.
Background and objective There is a dearth of studies on the clinical presentation of patients with post-pulmonary tuberculosis (PTB) sequelae and its impact on their quality of life (QoL). In light ...of this, we conducted this study to analyze the clinical profile and QoL in patients with post-PTB sequelae. Methods Patients with a history of treated PTB and evidence of radiological damage were enrolled prospectively from November 2018 till June 2020 to study their clinical profile and QoL as per the eligibility criteria. A detailed clinical history was taken along with posteroanterior-view chest X-rays and CT scans of the thorax with bronchial angiography in patients with hemoptysis. QoL was assessed using the Hindi version of St. George's Respiratory Questionnaire (SGRQ) for which permission was obtained from the St. George's University of London. SGRQ scores were calculated using score calculation algorithms (Microsoft Excel-based) and missing data imputation as recommended by its developer. Results A total of 174 patients were included in the analysis. The analyzed population was relatively younger (mean age: 44.27 years) with BMIs leaning toward the lower side of normal (median: 19.6 kg/m²); the majority of the patients were males (59%) and non-smokers (77%). PTB had been diagnosed clinico-radiologically in the majority (68%) of patients with non-compliance to antitubercular treatment (ATT) being reported by only 9% of patients. Multiple courses of ATT were received by about one-third of patients, mainly on a clinico-radiologic basis. Systemic hypertension (HTN) (11%) and diabetes mellitus (DM) (9%) were the most common comorbidities. The most common symptom complex found was cough, expectoration, and dyspnea (n=102, 59%). At least one incidence of massive hemoptysis was reported by 20% of patients. Bronchial artery embolization (BAE) was performed for moderate to massive hemoptysis in 26% of patients with a success rate of >90%. One-fifth of the study participants required hospitalization for exacerbation of respiratory symptoms with more than half of these (59%) requiring ventilatory support. Health-related QoL was significantly impaired as reflected by a median SGRQ total score of 45.53. The most affected domain of QoL was the activity domain (mean score: 45.47). Females had worse QoL as compared to males (p=0.0062), and so did underweight patients (p=0.048). The prolonged duration of the illness also significantly impaired the QoL (p<0.001, r=0.313). Conclusion The sequelae of PTB are under-recognized even among physicians and are frequently misdiagnosed as active PTB. The QoL is more severely affected due to residual damage. This study highlights the clinical profile of this patient population and underscores the need to recognize post-PTB sequelae as a separate entity. An important remedy to mitigate its long-term consequences is its inclusion and recognition in national and international TB guidelines to facilitate its early identification and promote further research to address its evidence-based management.
Background: Lignocaine can be administered during bronchoscopy using either a direct injection through the cricothyroid membrane (the cricothyroid method) or a spray of lignocaine solution through ...the bronchoscope working channel (the spray-as-you-go method). In this meta-analysis of randomized controlled trials (RCTs), we compared the efficacy of these two methods for topical anesthesia during flexible bronchoscopy. Methods: We performed a systematic search to extract the relevant RCTs comparing the two techniques. Results: Five RCTs meeting the inclusion criteria (747 subjects) were identified. The cricothyroid method was associated with significantly less cough (standardized mean difference SMD = −1.18, 95% confidence interval CI −1.75, −0.62, P < 0.001, significant heterogeneity I2 = 86%, P < 0.001). On analysis of secondary outcomes, the cricothyroid method was associated with a greater operator-rated procedure satisfaction (SMD = 1.00, 95% CI 0.74, 1.25, P < 0.001), less time for upper airway negotiation (mean difference, MD = −0.99, 95% CI −1.37, −0.6, P < 0.001), and a significantly less cumulative dose of lignocaine administered (MD = −68.12, 95% CI −130.18, −6.06, P = 0.03). The overall procedure duration (MD = 0.08, 95% CI −0.09, 0.24, P = 0.36) and patient discomfort (MD = −0.08, 95% CI −0.38, 0.22, P = 0.59) were not different between the two methods. There was no significant publication bias (P = 0.94). Conclusions: The cricothyroid method is associated with less cough during flexible bronchoscopy. Other advantages are a greater operator-rated procedure satisfaction at a less cumulative lignocaine dose. These findings highlight the superior performance characteristics of the cricothyroid method for lignocaine administration for flexible bronchoscopy.
Some of the important unanswered questions are – (1) Who performed ultrasonography of the diaphragm – a radiologist or respiratory physician? (2) How experienced was the operator? (3) What was ...posture of the patient while ultrasonography was performed? (4) Which machine was used? (5) How the zone of apposition measured? (6) How many readings were taken – single or multiple? (7) What was the reliability of the measurements taken? (8) How patients were recruited? (9) Was ethical clearance obtained for the conducted of study? Furthermore, there are guidelines for how to report randomized control trial, observation studies, case– control studies, etc., For observational study such as by Jain et al., following checklist provided in the STROBE guidelines 6 would minimize chances of missing any important aspect of the study. The purpose of the peer review is to maintain a high standard of reporting and control of dissemination of unwarranted or uncertain claims/views by authors.
Background
Endobronchial Ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic ...Ultrasound‐Guided Fine Needle Aspiration (EUS‐B‐FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches.
Methods
We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS‐TBNA or EUS‐B‐FNA (50 to each group). Co‐Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups.
Results
Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS‐TBNA 46/50; 92% and EUS‐B‐FNA 48/50;96%, P = 0.4) and diagnostic aspirates (EBUS‐TBNA 38/50; 76% and EUS‐B‐FNA 36/50;74%, P = 0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS‐B‐FNA approach. Procedure duration was significantly shorter with EUS‐B‐FNA 18.1(14.4) minutes versus 16.4 (49.6) minutes, P < 0.001. Minor complications occurred in one patient in the EBUS‐TBNA group and none in the EUS‐B‐FNA group.
Conclusion
During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS‐B‐FNA as compared with EBUS‐TBNA provides greater patient comfort with a similar diagnostic yield.
Aim: Globally, the incidence of lung cancer amongst women appears to be increasing. We aimed to compare the socio-epidemiological and clinical characteristics of lung cancer amongst men and women ...from a large cohort at a tertiary care hospital in Northern India. Methods: Records of patients diagnosed with lung cancer between January 2008 and March 2020 were reviewed. Baseline epidemiological data, clinical characteristics, histologic profiles, treatment administered, and survival were compared between males and females. Results: A total of 2054 male and 438 female patients were included in analysis. Compared to males, female patients were younger median age, 56 vs. 60 years, P < 0.001), less likely to be working, less educated beyond secondary level and less likely to be smokers (29.1% vs. 84.9%, P < 0.0001). No difference in baseline performance status was observed. Females were more frequently diagnosed with adenocarcinoma (54.2% vs. 30.2%, P = <0.0001), stage IV disease (70.8% vs. 63%, P = 0.001), and had higher rate of EGFR mutation (37.2% vs. 21.5%, P < 0.0001). There was no difference in the proportion of females receiving cancer-specific therapy. Multivariate Cox proportional hazards model revealed higher progression-free survival median 9.17 vs. 7.23 months; P = 0.007 and overall survival median 13.80 vs. 9.10 months respectively, P = 0.001 amongst females compared to males. Conclusion: Amongst a large cohort of lung cancer, females demonstrated several distinct and characteristic demographics as well as disease-related features, especially better survival outcomes.
The role of topical nasal vasoconstrictor administration during flexible bronchoscopy is unclear.
Consecutive subjects undergoing flexible bronchoscopy were randomized to receive either topical ...xylometazoline (0.1%) or placebo (saline nasal spray, 0.74% w/v isotonic solution) before bronchoscopy. Background topical anesthesia included 2% nasal lignocaine gel, pharyngeal spray of 10% lignocaine, and 1% lignocaine solution for spray-as-you-go administration. The primary outcome was the operator rated ease of nasal negotiation of the bronchoscope on the visual analog scale (Negotiation VAS). Secondary objectives included assistant rated facial pain scale score, patient-rated nasal pain score (Pain VAS), time to reach the vocal cords after bronchoscope insertion, operator rated nasal mucosal trauma score (Trauma VAS), hemodynamic changes, and complications between the groups.
In all, 148 subjects were recruited and randomized to the placebo (73) and xylometazoline groups (75). Operator rated ease of nasal bronchoscope negotiation (Negotiation VAS) was similar in both the groups Median (IQR), 1 (1–2) in both groups, p = 0.79. There were no differences in the other outcomes including assistant rated score of facial pain (Median (IQR), 2 (2–4) placebo and 2 (2–4) xylometazoline, p = 0.36, Pain VAS Median (IQR), placebo 2 (1–2) and xylometazoline 2 (1–3), p = 0.28, Trauma VAS, Median (IQR), placebo 1 (0–2) and xylometazoline 1 (0–1), p = 0.28, hemodynamic changes, or complications between the two groups.
The findings of this study do not support the administration of topical nasal xylometazoline in flexible bronchoscopy.
Trial registered on Clinicaltrials.gov, www.clinicaltrials.govNCT03424889, on January 02, 2018.
Background There is limited data on coronavirus disease 2019 (COVID-19) and latent tuberculosis infection (LTBI). Methodology We analyzed data of admitted COVID-19 patients evaluated for LTBI to ...examine the impact of LTBI on severity, laboratory parameters, and COVID-19 outcome. Prospectively collected data were analyzed for 60 patients who were administered the Mantoux tuberculosis skin test (TST) using five tuberculin units of purified protein derivative. All patients were administered TST irrespective of Bacille Calmette-Guérin (BCG) vaccination status. Comorbidities, clinical features, radiologic involvement, laboratory parameters, and clinical course were analyzed concerning LTBI. Results The mean age was 45.9 (±15.2) years, and 35 (58.3%) patients had non-severe disease. The vast majority (n = 56/60; 93.3%) had been vaccinated with single-dose BCG in infancy or early childhood, as per national immunization guidelines. LTBI was diagnosed in 15 (25%) patients. LTBI prevalence was lower in severe (n = 1/25; 4%) than non-severe (n = 14/35; 40%) COVID-19 (p = 0.01) patients. LTBI patients had lower percentage neutrophil count, higher lymphocyte percentage, higher monocyte count, lower neutrophil-lymphocyte (NL) ratio, lower alanine aminotransferase, lower C-reactive protein, and lesser radiologic involvement compared to those without LTBI (p < 0.05). Similarly, among the mild COVID-19 subgroup, those with LTBI had higher lymphocyte and monocyte counts and lesser radiologic involvement than those without LTBI (p < 0.05). Conclusions LTBI patients appear to have milder disease, higher lymphocyte and monocyte count, higher NL ratio, and lesser radiographic involvement. This observation needs to be studied in larger studies using interferon release assays.
Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no ...guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.
Dieulafoy's disease is an uncommon condition, the usual site of occurrence being the gastrointestinal tract. The condition refers to the presence of a dysplastic submucosal artery with mucosal ...vascular branches that has propensity to cause recurrent bleeding. Dieulafoy's disease of the bronchus is rare. Herein, we describe the case of a 26-year-old male who presented with recurrent bouts of hemoptysis and bronchial Dieulafoy's disease was diagnosed. Flexible bronchoscopy was performed, and argon plasma coagulation (APC) of the bleeding lesion was done. The procedure was successful and was followed by complete eradication of the vascular malformation and cessation of hemoptysis. APC is a useful tool in the armamentarium of an interventional pulmonologist that can allow rapid and safe control of bleeding from superficially located and bleeding endobronchial lesions, and can be easily and effectively applied using a flexible bronchoscope.
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