Utility of Serum Procalcitonin and Its Clearance in Predicting Outcomes in COVID-19 Patients.

Introduction Identification of coronavirus disease 2019 (COVID-19) patients at risk of worse clinical outcomes is crucial to improving patient care. Various biochemical markers have been used to predict outcomes in such patients. We aimed to evaluate the role of serum PCT (procalcitonin) and the utility of PCT clearance (PCTc) in predicting the outcome of patients with COVID-19 illness. Methods We prospectively included 39 patients with severe or critical COVID-19 illness with an age equal to more than 18 years. In addition to routine baseline investigations, serum PCT was measured at admission (PCT1) and day 5 of hospitalization (PCT2). PCTc was calculated using the formula [Formula: see text]. Results We observed that serum PCT at admission was significantly higher in non-survivors (median: 1.9 ng/ml IQR: 0.51-4.23) compared to survivors (median 0.35 (IQR: 0.1-1.2), p 0.002). On serial serum-PCT estimation, non-survivors had persistently elevated serum-PCT (median PCT1:1.9 ng/ml (IQR: 0.51-4.23) to median PCT2: 1.9ng/ml (IQR: 0.83-2.72), p 0.51) than survivors (median PCT1:0.35ng/ml (IQR: 0.1-1.19) to median PCT2: 0.15ng/ml (IQR: 0.05-0.29), p 0.01). However, no difference in serum PCTc was observed between the two groups (median: 35.3% (IQR: 12.5-84.9) in survivors vs. 71.7% (33.3-91.7) in non-survivors, p = 0.165). Conclusion Serum PCT is a potential biochemical marker that could predict outcomes in COVID-19 patients. Measurement of serial serum PCT and estimation of PCT clearance may serve as better predictors than a single value; however, well-designed studies are required to identify the definite role of serum PCT in COVID-19 patients of varying severity.

Addition of Mask to High-flow Nasal Oxygen: A Strategy to Improve Oxygenation in Hypoxemic Respiratory Failure Secondary to COVID-19.

PURPOSE: High-flow nasal cannula (HFNO) reduces the need for invasive mechanical ventilation in COVID-19 patients with hypoxemic-respiratory failure. During HFNO entrainment of room air dilutes the delivered fractional inspiratory oxygen (FiO2), thereby preventing improvement in oxygenation. The placement of a mask over HFNO to improve oxygenation has provided conflicting results. We aimed to determine and compare the effect of placing various mask types over HFNO on oxygen saturation (SPO2). MATERIALS AND METHODS: In this prospective physiological study 40 patients with COVID-19-associated hypoxemic respiratory failure on HFNO with O2 concentration <92% were included. The effect of placing different masks over HFNO on oxygenation, respiratory rate, heart rate, blood pressure, patient comfort, and partial pressure of carbon dioxide level (pCO2) was recorded after a prespecified time interval. RESULTS: We observed a significantly higher mean SPO2 and lower mean respiratory rate on using various study masks over HFNO compared to HFNO alone. On comparing various mask types, the use of N95 masks and nonrebreather (NRB) masks with O2 showed a significant increase in O2 concentration and reduction in respiratory rate compared to surgical mask (SM) and NRB without O2. The proportion of patients who achieved SPO2 of >92% was higher with the use of N95 masks (47.5%) or NRB with O2 (45%) over HFNO compared to SM (35%) and NRB without O2 (35%). No significant change was observed in heart rate, blood pressure, and CO2 level with the use of any mask over HFNO. CONCLUSION: This study demonstrates improvement in oxygenation and reduction in respiratory rate with the use of various masks over HFNO in patients of COVID-19-related hypoxemic-respiratory-failure. Significantly greater benefit was achieved with the use of N95 or NRB with O2 compared to SM or NRB without O2.

Clinical Profile and Quality of Life of Patients With Post-pulmonary Tuberculosis Sequelae Presenting to a Tertiary Care Hospital.

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.

Enhancing respiratory disease diagnosis by bronchoalveolar lavage in Kashmir: an audit of findings.

OBJECTIVE: To study bronchoalveolar lavage (BAL) findings in various respiratory diseases in children in Kashmir India. DESIGN: Prospective observational study. SETTING: Paediatric department of the tertiary care hospital. PATIENTS: Children of both genders from 1 month to 17 years of age INTERVENTION: All studied patients underwent flexible bronchoscopy and BAL. OUTCOME MEASURE: To observe the BAL findings in various respiratory diseases in the studied population. RESULTS: A total of 283 patients underwent BAL procedure. The positive BAL report was received in 131 (46%) patients. Out of these, 55 (42%) patients had positive BAL culture/ microscopy for different bacterial (50) and fungal species (Candida spp (3), Mucormycosis (1) and Aspergillus (1)). MTB was isolated in 25 (19%) patients. Twenty-three (17.5%) patients had bronchoalveolar lavage fluid (BALF) positive for pulmonary hydatidosis. Foamy macrophages were seen in 13 patients, significant eosinophilia in nine patients and hemosiderin-laden macrophages were seen in three patients. CONCLUSION: We found BALF a very useful sample for the evaluation of many infective and non-infective respiratory diseases in our region, which otherwise lacks high end diagnostics. 46% of our patients had some abnormalities in the BAL specimen. It provided us with valuable information regarding organism profile and drug sensitivity in case of lung infection. BALF analysis was also found useful in the diagnosis of some non-infective pulmonary disorders like acute eosinophilic pneumonia, aspiration syndromes and bronchial asthma.

Prevalence and predictors of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) varies over a wide range. Early detection and treatment of PE in AECOPD is a key to improve patient outcome. The purpose of the study was to investigate the prevalence and predictors of PE in patients of AECOPD in a high burden region of North India. MATERIALS AND METHODS: This prospective study included patients of AECOPD with no obvious cause of exacerbation on initial evaluation. Apart from routine workup, the participants underwent assessment of D-dimer, compression ultrasound and venous Doppler ultrasound of the lower limbs and pelvic veins, and a multidetector computed tomography pulmonary angiography. RESULTS: A total of 100 patients of AECOPD with unknown etiology were included. PE as a possible cause of AE-COPD was observed in 14% of patients. Among the participants with PE, 63% (n = 9) had a concomitant presence of lower extremity deep venous thrombosis. Hemoptysis and chest pain were significantly higher in patients of AECOPD with PE ([35.7% vs. 7%, P = 0.002] and [92.9% vs. 38.4%, P = 0.001]). Likelihood of PE was significantly higher in patients who presented with tachycardia, tachypnea, respiratory alkalosis (PaCO2 <45 mmHg and pH >7.45), and hypotension. No difference was observed between the two groups in terms of in-hospital mortality, age, sex distribution, and risk factors for embolism except for the previous history of venous thromboembolism (35.7% vs. 12.8% P = 0.03). CONCLUSION: PE was probably responsible for AECOPD in 14% of patients with no obvious cause on initial assessment. Patients who present with chest pain, hemoptysis, tachypnea, tachycardia, and respiratory alkalosis should be particularly screened for PE.

Spirometric abnormalities in patients with sleep-related breathing disorders.

INTRODUCTION: Patients with sleep-related breathing disorders (SRBD) have various structural and functional abnormalities of the upper airway during sleep which may get reflected on their pulmonary function tests. The aim of the study was to find the correlation between the spirometric indices and snoring, grades of apnea-hypoapnea index (AHI), and STOPBANG. There is scarcity of literature showing correlation of STOP BANG with spirometric variables. MATERIAL AND METHODS: Patient with SRBD fulfilling the inclusion and exclusion criteria were enrolled. The pretest probability sleep score STOPBANG and polysomnography (PSG) were calculated for all the patients. Spirometric indices like forced expiratory volume in one sec (FEV1), forced vital capacity (FVC), postbronchodilator ratio FEVI/FVC (PBDR), and peak expiratory flow rate (PEFR) were studied. Their association with snoring, different grades of obstructive sleep apnea (OSA), and STOPBANG were evaluated using statistical analysis. RESULTS: A total of 70 patients were enrolled. Abnormalities of spirometric indices were found to be common in patients with SRBD but their association with snoring, grades of OSA, and STOPBANG were not statistically significant. There is no statistically significant correlation between body mass index (BMI) and grades of AHI. CONCLUSION: This study found no statistically significant correlation between spirometric parameters and STOPBANG and degree of AHI. Primary care physicians should be aware that obstructive lung disease does coexist with the sleep disordered breathing but as per this study, their statistically significant association needs further validation.

Assessment of quadriceps muscle thickness using bedside ultrasonography by nurses and physicians in the intensive care unit: Intra- and inter-operator agreement.

BACKGROUND: Data regarding the agreement among multiple operators for measurement of quadriceps muscle thickness by bedside ultrasonography (USG) are sparse. AIM: To statistically assess the agreement among 5 operators for measurement of quadriceps muscle thickness on bedside USG. METHODS: This was a cross-sectional observational study. The 5 operators of varied experience (comprised of 1 critical care consultant, 2 fellows, and 2 nurses) independently measured quadriceps muscle thickness in triplicate for 45 critically ill patients each, using USG. Intra- and interrater agreement rates among the 5 operators were assessed using intraclass correlation coefficient (ICC) and expressed with 95% confidence interval (CI). RESULTS: The 5 operators produced a total of 135 readings and 675 observations for ICC calculations to determine the intraoperator and interoperator variations respectively. For intraoperator agreement, the overall ICC (95%CI) was 0.998 (0.997, 0.999) for operator 1, 0.998 (0.997, 0.999) for operator 2, 0.997 (0.995, 0.999) for operator 3, 0.999 (0.998, 0.999) for operator 4, and 0.998 (0.997, 0.999) for operator 5. For interoperator agreement, the overall ICC (95%CI) was 0.977 (0.965, 0.986; P < 0.001) for reading 1, 0.974 (0.960, 0.984; P < 0.001) for reading 2, and 0.975 (0.961, 0.985; P < 0.001) for reading 3. CONCLUSION: USG measurement of quadriceps muscle thickness was not dependent on clinical experience, supporting training for nurses in it.

Noninvasive ventilation-neurally adjusted ventilator assist for management of acute exacerbation of chronic obstructive pulmonary disease.

Patient-ventilator asynchrony is common with noninvasive ventilation (NIV) used for management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Neurally adjusted ventilator assist (NAVA) is a mode of ventilatory support which can minimize the patient-ventilator asynchrony. Delivering NIV with NAVA (NIV-NAVA) during acute exacerbation of COPD seems a logical approach and may be useful in reducing patient-ventilator asynchrony. However, there are no published reports which describe the use of NIV-NAVA for management of acute exacerbation of COPD. We describe the successful management of a 56-year-old gentleman presenting to the emergency department of our hospital with acute exacerbation of COPD with hypercapnic respiratory failure with NIV-NAVA.

All that wheezes is not asthma.

A young woman was admitted with respiratory failure. Prior to her admission, she had been treated for clinical bronchial asthma for about 2 years for recurrent wheezing. Endotracheal intubation was difficult. A fibroptic bronchoscopy, while the patient was ventilated, revealed a central tracheal tumour compromising >90% of the tracheal lumen. The tumour was cored out during rigid bronchoscopy while ventilating the patient through tracheostomy. Histopathology of the tumour was suggestive of adenoid cystic carcinoma.

Skin rash and subconjunctival haemorrhage in an adult with pandemic H1N1 influenza.

A young man presented with erythematous rash that appeared 3 days following upper respiratory symptoms and fever. Diffuse exanthematous rash was seen over whole body, most pronounced over the trunk. A subconjunctival haemorrhage also appeared in the left eye following incessant cough. Reverse transcription-PCR of the nasopharyngeal secretions revealed influenza A (2009 pandemic H1N1). The patient responded to oseltamivir therapy. Influenza should be considered in patients presenting with exanthematous skin rash.