Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations.

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

Fluticasone Furoate/Vilanterol Use Trends and Characteristics in Patients With Obstructive Airway Disease: A Real-World Study of 10,374 Patients From India.

Introduction Obstructive Airway Diseases (OADs) are the leading cause of death among chronic respiratory diseases worldwide, and novel therapies are direly needed. Fluticasone furoate/vilanterol (FF/Vi) (100/25 µg) is the first once-daily ICS/uLABA marketed in India for COPD since 2021. Considering its limited real-world experience in OAD patients in Indian clinical settings, a large drug utilization study (DUS) was planned. Methodology We conducted a cross-sectional, observational DUS at 1900 outpatient clinics in India from October 2021 to March 2022. Prescription data and medical history of patients who were prescribed the FF/Vi combination were collected. Results It was observed that FF/Vi was prescribed in an almost equal number of patients with COPD (44.2%) and asthma (42.9%). The majority of the patients (74%) were switched from previous ICS/LABA to this ICS/uLABA, while 26% of patients were treatment naïve. The average CAT score was 19.5±7.8 (43.2% GOLD Group C and 32.2% GOLD Group B) in COPD patients, while the average ACQ-5 score was 2.6±1.3 (33.1% GINA Step 3, 29.5% GINA Step 2) in asthmatic patients. Most of the patients (63.9%) had raised biomarkers (Blood eosinophil count >300 cells/µl). Prior history of exacerbation was present in 65% of patients with annual exacerbation rates of 1.2 in COPD, 1.1 in asthma, and 1.2 in asthma-COPD overlap syndrome (ACOS). Leukotriene inhibitors (42%) and LAMAs (30.8%) were common add-on medications. Conclusion We observed a trend towards a shift to once-daily ICS/uLABA (FF/Vi) by physicians, especially in symptomatic and exacerbating OAD patients with underlying comorbidities.

COVID-19-associated Pulmonary Cryptococcosis: A Rare Case Presentation.

Multiple case reports and case series report a surge in opportunistic infections like aspergillosis, mucormycosis, and reactivation of cytomegalovirus infection in coronavirus disease-2019 (COVID-19) patients. We hereby report the first case to the best of our knowledge of pulmonary cryptococcosis in a patient who had successfully recovered from severe COVID-19 illness. The pulmonary cryptococcosis spectrum ranges from asymptomatic infection to frank acute respiratory distress syndrome leading to respiratory failure. Pulmonary cryptococcosis is often underdiagnosed because its clinical presentation, radiographic features, and serologic laboratory investigations are generally inconclusive. The saprophytic colonization of fungus as opposed to invasive disease cannot be assessed from either culture of sputum or currently available serologic tests. Pulmonary cryptococcosis close association with COVID-19 can be further established with reporting of more cases. Hereby, we propose the term CAPC (COVID-19-associated pulmonary cryptococcosis) for such cases. How to cite this article: Sharma S, Agrawal G, Das S. COVID-19-associated Pulmonary Cryptococcosis: A Rare Case Presentation. Indian J Crit Care Med 2022;26(1):129-132.

Role of plasma exchange in management of patients clinically diagnosed of postpartum thrombotic microangiopathies: A retrospective observation from a tertiary health-care center.

INTRODUCTION: Diagnosis of postpartum thrombotic microangiopathies in pregnancy is a challenge, but plasma exchange (PE) is life-saving in such cases. This study was conducted with the aim to find the result of the early start of PE in such patients. MATERIALS AND METHODS: There were a total of seven clinically diagnosed cases of post partum thrombotic microangiopathies (PP-TMA) where PE was done. The diagnosis of PP-HUS and decision to start PE in such cases were based on the classical triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. All the PE procedures were done using fully automatic COM.TEC (Fresenius Kabi, Germany). RESULTS: Immediately before the start of PE, the mean platelet count and serum lactate dehydrogenase (LDH) and hemoglobin (Hb) were 53.1 × 109/L, 10,943 IU/L, and 6.4 gm%, respectively. After seven sessions of PE, platelet count improved to 158 × 109/L and LDH dropped to 609 IU/L, and Hb improved to 10.3 gm% (P < 0.05). We got a positive renal response in four patients in whom serum creatinine value reached within normal range while in the remaining three patients, no positive renal response was obtained and serum creatinine remained above normal range. Thus, the response of PE was shown to be inadequate in three patients. Compliance to PE was good. Patients were discharged after 20 days (mean) of hospital admission. CONCLUSION: PE is life-saving in PP-HUS. High degree of clinical suspicion to it and early start of PE were crucial for successful outcome in our patient population.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations.

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Atrial Myxoma-Related to Chronic Immunosuppression: A case report.

Although rare, atrial myxoma is the most common primary tumour of the heart. Its relation to immunosuppression in solid organ transplant is presently debateable. We report the case of a 71-year-old male patient who underwent renal transplant 17 years prior. Since that time he continued high dose immunosuppression without physician consultation and presented to us with atrial myxoma and its complications raising the question of any association between immunosuppression and the development of atrial myxoma.

Miliary nodules due to secondary pulmonary hemosiderosis in rheumatic heart disease.

Pulmonary hemosiderosis is defined as the clinical and functional consequence of iron overload of the lungs, which usually occurs due to recurrent intra-alveolar bleeding. It can manifest as miliary mottling and should be entertained in the differential diagnosis of patients presenting with miliary nodules on chest radiography, especially those with mitral stenosis. The management of secondary pulmonary hemosiderosis secondary to valvular heart disease includes valvuloplasty and/or valve replacement. The radiological opacities may disappear with successful treatment of the underlying valvular disease in many patients. However, they may persist with no physiological impairment to the patient. Here, we present a 32-year-old man with mitral stenosis who presented with fever and miliary shadows on chest radiography, which was ultimately diagnosed as secondary pulmonary hemosiderosis.