Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Role of circulatory miRNA-21 and associated signaling pathways in the pathogenesis of pulmonary fibrosis among individuals recovered after COVID-19 infection.

Introduction: Currently pulmonary fibrosis in post-COVID individuals represents a crucial milieu of investigation due to long-term associated complications and worse clinical outcome. Lack of studies in Indian population confers a crucial need for elucidating possible targets and mechanisms to explore better management and outcome. Hence, this study aimed to explore the role of circulating miRNA-21 in patients from South India after COVID-19 recovery, while targeting TGF-ß signaling pathway involved in the development of pulmonary fibrosis. Methods: This prospective, single centre, hospital-based study enrolled a total of 50 participants in the age group of 50 to 60 years including 25 non-infected controls and 25 patients who were recovered after 3-6 months of COVID-19 infection and presented radiological pulmonary abnormalities. Quantification of miRNA-21 and selected gene transcripts (TGF-ß, Col1A2, Col3A1, and α-SMA) was performed in plasma samples of both patients and controls. Results: Significantly increased expression levels of miRNA-21 was observed in patient samples compared to controls (4.50 ± 1.03 vs 12.60 ± 3.52, p < 0.0001) with 72.10% sensitivity and 80.10% specificity. Further, significantly increased levels of central fibrosis regulatory gene transcript TGF-ß (0.56 ± 0.27 vs 1.83 ± 0.98), two crucial collagen transcripts Col1A2 (0.62 ± 0.19 vs 1.56 ± 1.00) and Col3A1 (0.61 ± 0.27 vs 1.54 ± 0.89), and α-SMA (0.46 ± 0.17 vs 1.20 ± 0.78) was observed in patients compared to controls. Western-blot analysis also showed almost similar observations at proteins levels. Conclusion: Circulating miRNA-21 may provide crucial insights for elucidating TGF-ß mediated pulmonary remodeling involved in the fibrosis development and achieve better clinical outcome for post-COVID patients after recovery, in real-time with high diagnostic accuracy.

Small Airways, Big Problem: Extrafine beclomethasone/formoterol in asthma and chronic obstructive pulmonary disease.

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic respiratory diseases characterized by an inflammatory process that extends from the central to peripheral airways. Conventional pressurized metered-dose inhalers and most dry-powder inhalers emit drug particles too large to target the small airways effectively. Advancements in drug formulation have given rise to a new generation of inhalers that can generate aerosols with extrafine drug particles that leads to more effective aerosol penetration into the lung periphery. An extrafine formulation of inhaled beclomethasone/formoterol (BDP-FF) with enhanced lung deposition is now available. This document reviews the various real-world and controlled studies that have evaluated the efficacy of extrafine BDP-FF in asthma and COPD.

Management of community-acquired bacterial pneumonia in adults: Limitations of current antibiotics and future therapies.

Community-acquired bacterial pneumonia (CABP) is one of the leading causes of morbidity and mortality in India and worldwide. Evidence indicates that Gram-positive, Gram-negative, and atypical bacteria are encountered with near-equal frequency. Despite guideline recommendations and antibiotic options for the management of CABP, burden of morbidity and mortality is high, which is attributable to a variety of factors. Failure of empirical therapy, probably because of insufficient microbial coverage, increasing bacterial resistance, and adverse effects of existing treatments, underlies the unsuccessful treatment of CABP, especially in India. Multiple novel therapies that have entered clinical development phases have potential to address some of these issues. This article discusses the current treatment guidelines in CABP, management limitations, and emerging potential treatment options in the management of CABP.

Active pulmonary tuberculosis presenting with acute respiratory failure.

Four patients with active pulmonary tuberculosis (PTB) presenting with respiratory failure are reported here. Bronchogenic PTB, simulating an acute febrile illness or diffuse interstitial lung disease with short duration of symptoms, as a cause of acute respiratory failure is less recognized. If diagnosed and treated early, it has good prognosis. Three of the four patients presented here had an acute presentation with fever, dyspnoea, and hypoxemia with diffuse infiltrative lesions on radiography, and the other younger patient presented predominantly with lobar consolidation. These patients presenting with respiratory failure required intensive care management, and a diagnosis was made with bronchoalveolar lavage fluid and transbronchial lung biopsy. All four patients promptly received antitubercular therapy, showed clinicoradiological improvement, and were stable at 1 year follow up.

Consensus Recommendation for India and Bangladesh for the Use of Pneumococcal Vaccine in Mass Gatherings with Special Reference to Hajj Pilgrims.

Respiratory tract infections are prevalent among Hajj pilgrims with pneumonia being a leading cause of hospitalization. Streptococcus pneumoniae is a common pathogen isolated from patients with pneumonia and respiratory tract infections during Hajj. There is a significant burden of pneumococcal disease in India, which can be prevented. Guidelines for preventive measures and adult immunization have been published in India, but the implementation of the guidelines is low. Data from Bangladesh are available about significant mortality due to respiratory infections; however, literature regarding guidelines for adult immunization is limited. There is a need for extensive awareness programs across India and Bangladesh. Hence, there was a general consensus about the necessity for a rapid and urgent implementation of measures to prevent respiratory infections in pilgrims traveling to Hajj. About ten countries have developed recommendations for pneumococcal vaccination in Hajj pilgrims: France, the USA, Kuwait, Qatar, Bahrain, the UAE (Dubai Health Authority), Singapore, Malaysia, Egypt, and Indonesia. At any given point whether it is Hajj or Umrah, more than a million people are present in the holy places of Mecca and Madina. Therefore, the preventive measures taken for Hajj apply for Umrah as well. This document puts forward the consensus recommendations by a group of twenty doctors following a closed-door discussion based on the scientific evidence available for India and Bangladesh regarding the prevention of respiratory tract infections in Hajj pilgrims.

Regression of pulmonary artery hypertension due to development of a pulmonary arteriovenous malformation.

Idiopathic Pulmonary Hypertension (IPAH) is characterized by elevated pulmonary arterial pressure in the absence of an identifiable underlying cause. The condition is usually relentlessly progressive with a short survival in the absence of treatment.(1) We describe a patient of IPAH in whom the pulmonary artery pressures significantly abated with complete disappearance of symptoms, following spontaneous development of a pulmonary arterio-venous malformation (PAVM).

Pulmonary alveolar proteinosis due to mycophenolate and cyclosporine combination therapy in a renal transplant recipient.

Pulmonary alveolar proteinosis (PAP) is an orphan disease characterized by the accumulation of excess of surfactant within alveoli and bronchioles. The primary form of PAP (P-PAP; also referred to as idiopathic or autoimmune) is the most common form. It is mediated through a circulating neutralizing antibody against granulocyte-macrophage colony-stimulating factor. Secondary PAP (S-PAP) can be induced by a host of inciting agents and is far more liable to progress to terminal respiratory failure. We describe a rare case of S-PAP occurring in a renal transplant recipient due to mycophenolate and cyclosporine combination-therapy, which resolved spontaneously following withdrawal of these drugs.

Glutamate decarboxylase and GABA aminotransferase levels in different regions of rat brain on the onset of Leptazol induced convulsions.

The activities of Glutamate decarboxylase (GAD) and Gamma aminobutyric acid (GABA) were studied in three regions of rat brain in heightened neuronal activity resulting in convulsions by Leptazol. These enzymes were studied in preconvulsive, convulsive and post convulsive phases. The activity of GAD decreases significantly in the preconvulsive phase in all the three regions of brain followed by a significant increase during the convulsive and post convulsive phase in cerebral cortex and cerebellum. The activity of GABA-T decreases maximal during the preconvulsive phase followed by convulsive phase. The activity of this enzyme tended to increase to control values when the postconvulsive phase was reached. Therefore, it is suggested that the concomitant decrease of GAD activity and GABA concentration, is probably an important factor in the onset of convulsions.

Correlation of clinical profiles with obstructive sleep apnea and metabolic syndrome.

BACKGROUND: Obstructive sleep apnea (OSA) is a common condition being increasingly recognized and is associated with many diseases. Few data are available for Indian patients and public health hazard of the condition continues to be seriously underestimated in this country. The objective of this study was to evaluate the prevalence of obesity, hypertension, diabetes mellitus, and hyperlipidemia (HLP) in a South Indian population with proven OSA. METHODS: A retrospective analysis of data accrued in patients undergoing polysomnography (PSG) was undertaken. Two hundred thirty-four patients of either sex in the age of 54 ± 11 years who tested positive for OSA were compared with control group. An apnea-hypopnea index (AHI) of >5 in the presence of snoring and daytime somnolence was taken to define sleep apnea. RESULTS: The mean AHI among the study group with OSA was 31.3 ± 18.6 as compared with 1.2 ± 0.5 in the control group. The BMI among patients with OSA was 36 ± 6 as compared with 29 ± 4 in comparison group (p < 0.001). Among the patients with OSA, 31% were having HLP, 59% were diabetics, and 86% were hypertensive. Subjects with PSG-proven OSA had significant levels of day time sleepiness, lack of concentration, changes in mood, morning headache, and dry mouth. Nonrestorative sleep, awakening with choking, nocturnal dyspnea, insomnia with frequent awakenings, nocturia, and diaphoresis were observed in (>80%) patients. A significant difference in the sleep efficiency (16%), sleep onset (14%), and mean saturation (9%) was observed in the study group as compared to the control group. CONCLUSIONS: The risk of obesity, hypertension, diabetes mellitus, and HLP in OSA syndrome patients was almost three times more than that of the comparing group.

Tracheopathia osteoplastica presenting with haemoptysis in a young male.

A young man presented with infrequent haemoptysis spanning over 10 years. Chest radiograph was normal. However, the computed tomography (CT) of the chest had shown endotracheal wall changes. The diagnosis of tracheopathia osteoplastica was suggested on fiberoptic bronchoscopy and confirmed histologically.

Multinodular goiter compressing the trachea following open heart surgery.

Acute hemorrhage into an adenomatous goiter following cardiac surgery is a rare cause of acute upper airway obstruction. We report an unusual presentation of respiratory distress in a patient with goiter recovering from open heart surgery, which was successfully treated by left hemithyroidectomy. A mandatory evaluation of the upper trachea in patients with long-standing benign goiter is recommended prior to cardiac surgery.