Rehabilitation in obstructive sleep apnea: an ignored treatment adjunct.

Patients with obstructive sleep apnea (OSA) remain physically inactive during the day, are deconditioned, and have an impaired health-related quality of life (HRQoL). The role of rehabilitation is not yet defined in OSA, despite proven effective modalities for chronic illnesses like chronic obstructive pulmonary disease. In this prospective study, over a period of one year, 30 individuals with sleep-disordered breathing were included. Before recruitment, every patient was receiving continuous positive airway pressure treatment for at least 4 weeks. A statistically significant negative correlation was seen between the apnea hypopnea index and reductions in 6-minute walk distance, energy, and general health, which signified that patients with greater levels of daytime sleepiness have poor quality of life and are more deconditioned. Enrolled patients in the study underwent a 20-session rehabilitation program (with a minimum of 2 sessions per week). The patient received resistance and endurance exercises, dietary guidance, and counseling at each session. Before and after rehabilitation, target parameters such as 6MWD, HRQoL domains, Epworth sleepiness scale (ESS), and body mass index (BMI) were recorded. All 8 HRQoL domains showed improvement post-rehabilitation. Along with improvements in ESS and BMI, the 6MWD was also improved. No adverse event such as cardio-respiratory distress occurred in individuals undergoing rehabilitation. To conclude, rehabilitation is a safe and efficacious modality as an adjunct to positive airway pressure therapy in OSA patients.

Comparative yield of transbronchial cryo-nodal biopsy, transbronchial intra-nodal forceps biopsy, and transbronchial needle aspiration for mediastinal lesions at a tertiary care center in India (COLD-FORCEPS study).

Endobronchial ultrasound (EBUS) guided mediastinal cryobiopsy, and intranodal forceps biopsy are newer modalities for sampling mediastinal lymph nodes. The data regarding the diagnostic yield of both modalities is scarce. Patients were recruited retrospectively from our existing database. Patients who had undergone both an EBUS guided mediastinal cryobiopsy and an intranodal forceps biopsy were enrolled in the study. The final diagnosis was made with a clinical-pathological-radiological assessment and clinico-radiological follow-up after one month. A total of 34 patients were enrolled in the study who had undergone both EBUS guided mediastinal cryobiopsy and intranodal forceps biopsy and had complete data available, including 1-month follow-up data. The sample adequacy rate of EBUS-transbronchial needle aspiration (EBUS-TBNA), EBUS-TBNA with mediastinal cryobiopsy, and EBUS-TBNA with intranodal forceps biopsy was 94.11%, 97.05%, and 94.11%, respectively (p=0.56). The diagnostic yield achieved in EBUS-TBNA, EBUS-TBNA with mediastinal cryobiopsy, and EBUS-TBNA with intranodal forceps biopsy was 73.52%, 82.35%, and 79.41%, respectively (p=0.38). No major complications were seen in any patient. To conclude, adding EBUS guided mediastinal cryobiopsy and intranodal forceps biopsy to EBUS-TBNA may not be superior to routine EBUS-TBNA.

Post-extubation high-flow nasal cannula oxygen therapy versus non-invasive ventilation in chronic obstructive pulmonary disease with hypercapnic respiratory failure.

The sequential use of non-invasive ventilation (NIV) for weaning in hypercapnic respiratory failure patients is a recommended practice. However, the effectiveness of weaning on High flow nasal cannula (HFNC) is unclear. Chronic obstructive pulmonary disease patients with hypercapnic respiratory failure who received invasive ventilation were screened for enrolment. This study was a single-centre, prospective, randomized comparative study. The primary outcome was treatment failure within 72 hours after extubation. Patients who were screened positive for extubation were enrolled in the study and randomized into the HFNC group and NIV group using a computer-generated simple randomization chart. The treatment failure was defined as a return to invasive mechanical ventilation, or a switch in respiratory support modality (i.e., changing from HFNC to NIV or from NIV to HFNC). Of 72 patients, 62 patients were included in the study. Treatment failure occurred in 8 patients (26.67 %) in HFNC group and 8 patients in NIV group (25%) (p=0.881). The mean duration of ICU stay in HFNC group was 5.47±2.26 days and 6.56±3.39 in NIV group (p=0.376). In the current study, HFNC was non-inferior to NIV in preventing post-extubation respiratory failure in COPD patients, while HFNC had better treatment tolerance.

Comparison of immediate withdrawal and stepwise reduction in duration of non-invasive ventilation in chronic obstructive pulmonary disease patients presenting with acute hypercapnic respiratory failure.

There is no universally acceptable protocol for the withdrawal of non-invasive ventilation (NIV) in chronic obstructive pulmonary disease (COPD) patients presenting with acute hypercapnic respiratory failure (AHcRF). This study was carried out to evaluate immediate against stepwise reduction in NIV. Sixty COPD patients with AHcRF who were managed with NIV were randomized into two groups - immediate NIV withdrawal (Group A), and stepwise reduction of NIV duration (Group B). The rate of successful NIV withdrawal, time to recurrence of hypercapnic respiratory failure, total duration of NIV use, and hospital length of stay (LOS), were compared among the 2 groups. NIV was successfully withdrawn in 51/60 (85%) patients. NIV was successfully withdrawn in 24/30 (80%) patients in Group A and 27/30 (90%) patients in Group B (p=0.472). The total duration of NIV use was significantly lower in Group A (38.97±17 hours) as compared to Group B (64.3±7.74 hours) (p<0.0001). The hospital LOS was significantly lower in group A (5.8±1.6 days) as compared to Group B (7.7±0.61 days) (p<0.0001). To conclude, immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible and does not increase the risk of weaning failure.

Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index.

Background: Diaphragmatic dysfunction has been increasingly documented to play a critical role to determine ventilator dependency and failure of weaning. Objective: The goal was to study the diagnostic accuracy of diaphragmatic rapid shallow breathing index (D-RSBI) as a predictor of weaning outcomes in comparison to RSBI. Materials and methods: A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. The right hemidiaphragm displacement [diaphragm displacement (DD)] was calculated by M-mode ultrasonography, and respiratory rate (RR) and tidal volume (TV) were documented from the ventilator readings. Rapid shallow breathing index (RSBI) was measured as RR/TV (in liters); D-RSBI was calculated as RR/DD (in millimeters) and expressed as breath/minute/millimeter. Extubation failure was defined as the reinstitution of mechanical ventilation at the end of, or during the spontaneous breathing trial (SBT), re-intubation or the need of noninvasive ventilation (NIV) for the patient within 48 hours of extubation. Results: Of 101 screened patients, 50 patients met the inclusion criteria, of whom 45 patients had successful SBT, and finally, 41 patients could be successfully extubated. Hence, the overall rate of weaning failure in the study population was 18%. The areas under the receiver operator characteristic (ROC) curves for D-RSBI and RSBI were 0.97 and 0.70, respectively (p <0.0001). The Pearson's correlation among RSBI and D-RSBI was 0.81 (p-value <0.001). Conclusion: Diaphragmatic rapid shallow breathing index has a positive correlation and greater diagnostic accuracy than RSBI, the conventional weaning index. How to cite this article: Shamil PK, Gupta NK, Ish P, Sen MK, Kumar R, Chakrabarti S, et al. Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index. Indian J Crit Care Med 2022;26(9):1000-1005.

Pulmonary alveolar microlithiasis: Blizzard of lung.

Pulmonary alveolar microlithiasis (PAM) is a rare inherited disorder in which patients present with either nonspecific signs and symptoms or are asymptomatic. Clinical-radiological dissociation is a commonly seen feature of the disease. Majority of cases are diagnosed in second and third decade of life, although presentation in paediatric and elderly population is also reported. Pathognomonic radiological findings, with normal calcium and phosphate levels can confirm the diagnosis without the need of further investigations in large number of cases. A high index of suspicion and knowledge of the disease is of paramount importance as it has a wide range of presentation and variable course thus posing a diagnostic challenge. We present two cases of this rare disease in elderly females with distinct presentations although with similar and characteristic radiological findings along with a brief review of literature of the disease.

Role of esophageal manometry in polysomnography of patients with chronic respiratory failure.

Esophageal pressure (Pes) monitoring is performed during polysomnography (PSG) with a thin, water-filled catheter connected to a transducer. The resulting quantitative assessment of respiratory effort can aid in the accurate diagnosis of sleep-related breathing disorders. This was a prospective observational study using Pes in PSG for thirty patients with chronic respiratory failure (CRF) conducted in the Department of Pulmonary, Critical Care and Sleep Medicine at a tertiary care centre of North India. Sleep scoring was done by conventional method and using esophageal manometry and compared polysomnography normal without esophageal manometry recording (PSGN) and polysomnography with esophageal manometry scoring (PSGE). Apnea hypopnea index (AHI) index was similar in both groups. However, respiratory effort related arousals (RERAs) were diagnosed easily using Pes resulting in significant increase in respiratory disturbance index (RDI) and even reclassification in terms of severity of sleep apnea. Besides, Pes was also useful to distinguish obstructive from central hypopnea which cannot be distinguished by routine PSG which can help guide therapy particularly in chronic respiratory failure patients with hypoventilation. Such patients with hypoventilation often require bilevel positive airway pressure as ventilatory support. Central hypopneas and apneas with hypercapnia may require higher-pressure support, a backup rate or even advanced volume assured modes of ventilation. Thus, it can be concluded that Pes in PSG remains a safe and generally well-tolerated procedure. Use of Pes aids to detect RERA and thereby RDI; a better marker of sleep-related breathing disorder rather than AHI. It also helps in differentiating between obstructive and central hypopnea.

A middle-aged lady with near-fatal respiratory failure.

Tuberculosis is an uncommon cause of acute hypoxemic respiratory failure. We present a case of a middle-aged women with near-fatal respiratory failure due to underlying tuberculosis with favorable clinical recovery. Early diagnosis and treatment are imperative to prevent morbidity, mortality, and disease transmission.

Diagnostic accuracy and feasibility of portable sleep monitoring in patients with obstructive sleep apnea: Re-exploring the utility in the current COVID-19 pandemic.

Portable sleep monitoring (PSM) is a promising alternative diagnostic tool for Obstructive Sleep Apnea (OSA) especially in high burden resource limited settings. We aimed to determine the diagnostic accuracy and feasibility of PSM device-based studies in patients presenting for evaluation of OSA at a tertiary care hospital in North-India. PSM studies (using a Type-III PSM device) were compared for technical reliability and diagnostic accuracy with the standard laboratory-based Type-I polysomnography (PSG). Patients were also interviewed about their experience on undergoing an unsupervised PSM studies. Fifty patients (68% males) were enrolled in the study, of which only 30% patients expressed their concerns about undergoing unsupervised PSM studies which included safety issues, ease of use, diagnostic accuracy, etc. Technical acceptability criteria were easily met by the PSM studies with signal loss in 12% studies (complete data loss and inaccessible data in 6% studies), warranting repetition sleep studies in four patients. The overall sensitivity of PSM device (AHI ≥5) was 93.5% (area under curve; AUC: 0.87). The diagnostic accuracy was 68.5%, 80%, and 91.4% for mild, moderate, and severe cases of OSA, respectively. An overall strong correlation was observed between PSM-AHI (apnoea-hypopnoea index) and PSG (r>0.85, p≤0.001), especially in severe OSA. The observed sensitivity was >90% for AHI>20 (clinically significant OSA), with high specificity of 91% for severe OSA (AUC: 0.94, 0.97 for AHI>20, AHI>30 respectively). The overall Bland-Altman concordance analysis also demonstrated only a small dispersion for PSM studies with a Cronbach's coefficient of 0.95. Therefore, there is good diagnostic accuracy as well as feasibility of home-based portable sleep studies in Indian patients. It can be promoted for widespread use in high burden countries like India for diagnosing and managing appropriately selected stable patients with high clinical probability of OSA, especially during the ongoing crises of COVID-19 pandemic.

Cocaine abuse induced diffuse alveolar haemorrhage: a rare entity.

Diffuse alveolar haemorrhage (DAH) is characterised by diffuse pulmonary opacities, respiratory failure, a falling haemoglobin level along with presence of hemosiderin-laden macrophages on bronchoalveolar lavage (BAL). Finding the underlying aetiology of DAH can be challenging but of importance as the treatment and prognosis are largely determined by it. We report a case of DAH with underlying cocaine abuse, a rare cause for the same.

Profile of sleep disordered breathing in heart failure with preserved ejection fraction.

Heart failure (HF) with preserved ejection fraction (HFpEF) represents nearly half of HF cases and is increasingly being recognized as a cause of morbidity and mortality. Hypertension (essential or secondary) is an important risk factor of HFpEF, owing to permanent structural changes in heart. A common cause of secondary hypertension is obstructive sleep apnea (OSA). In the present study, we have attempted to seek the frequency and characteristics of sleep disordered breathing (SDB) in HFpEF. Also, we tried to investigate if any correlation exists between the severity of SDB and the severity of diastolic dysfunction. This was a prospective, cross-sectional, case-control study in which 25 case patients with HFpEF and 25 control subjects were included. All the case patients and control subjects went through a detailed clinical, biochemical, echocardiography evaluation and overnight polysomnography. SDB was seen in 64% of the case patients having HFpEF and in 12% of control group with [odds ratio (OR)= 12.2, 95% confidence interval (CI) = 2.83-52.74; p<0.001]. A significant correlation of apnea-hypopnea index (AHI) severity was observed with degree of diastolic dysfunction (r = 0.67; p<0.001). Among HFpEF patients with SDB (16/25), 13 had OSA and only 3 had central sleep apnea (CSA). CSA was present in patients with severe diastolic dysfunction. There were no clinical or sleep quality differences among the OSA and the CSA group. To conclude, a higher frequency of SDB is observed in HFpEF patients. AHI severity correlates with degree of diastolic dysfunction. The underlying mechanisms of correlation between SDB and diastolic dysfunction either through uncontrolled hypertension or direct causation warrant further evaluation.

Sleepless in COVID-19: how not to lose sleep in lockdowns.

The corona virus disease 2019 (COVID-19) outbreak started in December 2019 in Wuhan, China, and spread all over the world leading to declaration of a pandemic by World Health Organization (WHO) on 11th March 2020. Most countries around the world have been on lockdown in an effort to halt the spread of virus. People around the world have been pushed into uncharted waters of uncertainty, fear, anxiety, stress and depression due to economic crash down, job losses and fear for their own health and that of their loved ones. There is a known association between anxiety/stress and sleep disturbances and vice versa. The most vulnerable population in this isolation like condition, in this lockdown, are the chief earning member of the family, women, young ones, and people with psychiatric illness.

COVID-19: Avoiding a second tragedy in a tuberculosis burdened country.

To the Editor Novel Coronavirus disease (COVID-19) was first notified in December 2019 from Wuhan, China. Now, it has spread rapidly and has been declared a pandemic affecting over 200 countries with widespread morbidity and mortality. It has been postulated that the most vulnerable population are the elderly, people living in crowded areas, children and immune-compromised individuals, such as people living with human immunodeficiency virus (HIV). The correlation of tuberculosis (TB), HIV and malnutrition are well documented and hence, people with tuberculosis should be considered as special population in this pandemic. TB is an ancient disease among humans recorded as far back as seventy thousand years which was declared a global public health emergency in 1993 by the World Health Organisation (WHO). India has the highest TB burden in the world.

Cerebral Malaria: Hear before Discharge!

How to cite this article: Joshi A, Gupta N, Ish P, Chakrabarti S. Cerebral Malaria: Hear before Discharge! Indian J Crit Care Med 2020;24(3):212-213.

Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study.

BACKGROUND: Post-intensive care survivors have decreased quality-of-life scores and prolonged cognitive dysfunction due to baseline factors and events related to intensive care unit admission, which remain largely unrecognized. MATERIALS AND METHODS: A prospective observational cohort study to assess the quality of life and occurrence of cognitive dysfunction, 3 and 6 months following discharge from the intensive care unit, was carried out. We enrolled 136 adults presenting to the intensive care unit with no prior cognitive dysfunction or depression and followed up and assessed them with repeatable battery for the assessment of neuropsychological status (RBANS) and quality of life with short Form-36 (SF-36) health survey. RESULTS: The incidence and prevalence of cognitive dysfunction was 100% at 3 and 6 months, respectively, as assessed by RBANS with a global cognition scores at 3 and 6 months of 71 (IQR 68.5-73) and 74 (IQR 72-86), respectively. Higher Charlson's comorbidity score, increased severity of illness, longer duration of mechanical ventilation, pain, delirium, coma, and hospital stay were associated with statistically significant lower scores at 3 months. The median SF-36 mental component score (MCS) and physical component score (PCS) at 3 months were 38.4 and 32.5 and at 6 months were 38.2 and 32.6, respectively. Poor score was associated significantly with advancing age, poor functional parameters at baseline as evidenced by clinical frailty, poor baseline Katz ADL scores, increased severity of illness, longer duration of mechanical ventilation, occurrence and duration of delirium, coma, pain, and usage of sedatives with or without analgesics. CONCLUSION AND CLINICAL SIGNIFICANCE: Patients discharged from the intensive care unit are at high risk for persistent cognitive impairment and poor quality of life score. Poor baseline patient characteristics and events occurring in ICU are associated with worse cognition and quality of life scores. There is an urgent need to prevent, diagnose, and manage these patients by optimizing intensive care practices. HOW TO CITE THIS ARTICLE: Balasubramanian V, Suri JC, Ish P, Gupta N, Behera D, Gupta P, et al. Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study. Indian J Crit Care Med 2020;24(10):932-937.

Microscopic polyangiitis in a case of silica exposure: a rare presentation.

A 28-year-old male was admitted for breathlessness, haemoptysis, fever and fatigue. The patient had occupational exposure to silica dust. Arterial blood gas test ABG revealed hypoxemic respiratory failure. Chest CT demonstrated ground glass opacities with interlobular septal thickening and small centrilobular nodules with patchy areas of consolidation in bilateral lungs. He was mechanically ventilated for refractory hypoxemia. The treatment with cyclophosphamide and methylprednisolone lead to recovery and extubation. The final diagnosis was diffuse alveolar haemorrhage due to perinuclear antineutrophil cytoplasmic antibody (ANCA)-associated microscopic polyangiitis (p-ANCA-associated MPA). In a tuberculosis endemic country, for patients presenting with diffuse alveolar haemorrhage (DAH), with history of silica exposure, differential diagnosis of ANCA associated vasculitis must be considered.

An uncommon cause of diffuse alveolar hemorrhage in a young male.

It is uncommon for Systemic lupus erythematosus (SLE) to present with diffuse alveolar hemorrhage (DAH) as the initial presentation. To diagnose this in a young male with no renal involvement is further uncommon. We report a case of a 16-year-old boy, who presented with hemoptysis and was eventually diagnosed as DAH with underlying SLE. Treatment with steroids and immunosuppressant helped in rapid recovery from this potentially life-threatening condition. This case highlights the need of defining diagnostic criteria for SLE in patients presenting as DAH and formulating guidelines for treatment of the same, especially in absence of co-existing lupus nephritis.

Diagnostic utility of endobronchial ultrasound features in differentiating malignant and benign lymph nodes.

Endobronchial ultrasound (EBUS) features have been shown to be useful in predicting etiology of enlarged malignant lymph nodes. However, there is dearth of evidence especially from developing countries. We assessed the EBUS characteristics across various mediastinal and hilar lymphadenopathies. In this prospective study, all patients with mediastinal and hilar lymphadenopathy on CT Chest and who were planned for EBUS-FNA (Fine Needle Aspiration) were included. EBUS features of lymph nodes studied were shape, size, margins, echogenicity, central hilar structure (CHS), coagulation necrosis sign and colour power doppler index (CPDI). These were scored and compared between benign and malignant lymphadenopathies. A total of 86 lymph nodes in 46 patients were prospectively studied of which 23 (26.7%) were malignant, 27 (31.3%) tuberculosis and 36 (41.8%) sarcoidosis. There was significant difference between malignant and benign lymph nodes in terms of CHS [central hilar structutre] (p=0.011), margins (p=0.036) and coagulation necrosis sign (p<0.001). On comparison of features of malignancy and tuberculosis, there were significant differences in margins (p=0.016) and coagulation necrosis sign (p 0.001). However, when malignancy and sarcoidosis was compared, there were differences in echogenicity (p=0.002), CHS (p=0.009) and coagulation necrosis sign (p<0.001). Only coagulation necrosis sign was found to be highly consistent with malignant lymph nodes. The other features cannot be used to distinguish malignant from benign lymph nodes, especially in a developing country like India where tuberculosis is a common cause of mediastinal lymphadenopathy.

Anaemia secondary to erythropoietin resistance: important predictor of adverse outcomes in chronic obstructive pulmonary disease.

PURPOSE: Anaemia is increasingly being linked to chronic obstructive pulmonary disease (COPD) as comorbidity with erythropoietin resistance secondary to chronic inflammation is hypothesised to have some role. This study purported to evaluate the occurrence of anaemia in COPD and its association with inflammatory markers, erythropoietin levels, severity and exacerbations of COPD. METHODS: Two hundred patients with COPD (90% men, mean age 62.4±8.33 years) were enrolled and subjected to detailed clinical and laboratory evaluation, including complete blood count, erythropoietin levels, C-reactive protein (CRP), pulmonary function test, blood gas analysis and chest X-ray. Severity of COPD was defined on the basis of forced expiratory volume in 1 s according to GOLD guidelines. RESULTS: Anaemia was diagnosed in 14% of patients (n=28, predominantly normocytic normochromic type (92.8%)) and polycythmia in 5% of patients (n=10). The prevalence of anaemia increased with increasing severity of COPD (stage 2: 8%, stage 3: 14.4% and stage 4: 17.2%; p=0.46). Serum erythropoietin was significantly higher in more advanced COPD, with mean levels being 30.2±6.5, 31.78±8.09 and 39.33±7.68 mIU/mL in stage 2, 3 and 4 respectively. Moreover erythropoietin levels inversely correlated with mean haemoglobin levels(r=-0.25), indicating erythropoietin resistance. CRP reactivity increased with increasing stage of disease in patients with anaemia (p=0.026). On follow-up, significant inverse correlation was observed between haemoglobin and COPD exacerbations (p<0.001). CONCLUSIONS: Anaemia is a significant comorbidity of COPD with a negative prognostic impact on lung health. It can be ascribed to a state of systemic inflammation resulting in blunting of erythropoietin response with increasing severity of disease, leading to greater morbidity and hospitalisation.