Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition).

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Pulmonary Cryptococcosis in HIV- sero-negative patients: case series from India.

Pulmonary cryptococcosis is likely to be misdiagnosed due to relatively non-specific clinical and radiological features. It is more frequently associated with immuno-suppressed conditions especially acquired immuno-deficiency syndrome (AIDS) and pulmonary tuberculosis (PTB). Four cases of pulmonary cryptococcosis were diagnosed over a period of eleven years. All patients in this case series were human immune-deficiency virus (HIV)-negative. The predisposing factors in these patients were diabetes mellitus (DM), acute lymphoblastic leukaemia (ALL), post-partum and pregnancy in one each of the patients. Relapse was seen in two cases. All the patients survived due to strict follow-up. Pulmonary cryptococcosis is common in non-AIDS patients and it warrants rapid diagnosis, treatment and follow-up to prevent relapse.

Primary Malignant Melanoma of the Lung: Case Report and Literature Review.

Primary malignant melanoma of the lung (PMML) is an extremely rare tumour with only sporadic case reports. We report the occurrence of PMML in a 58-year-old female. Although extremely rare, it must be considered in the differential diagnosis of bronchogenic carcinoma and a detailed systemic examination must be done to rule out any primary skin or eye involvement.

Consensus & evidence-based INOSA Guidelines 2014 (first edition).

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive sleep apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or co-morbidities or ≥ 15 such episodes without any sleep related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Bronchoscopic resection of endobronchial inflammatory myofibroblastic tumor: A case report and systematic review of the literature.

Inflammatory myofibroblastic tumour (IMT) is a rare tumour affecting the tracheo-bronchial tree in the adult population. The clinical presentation of this tumour is diverse and diagnosis can be definitively clinched by histopathological examination. Treatment of this tumour usually requires surgical resection with bronchoscopic resection being described in few cases. We describe a 32 year old male presenting with hemoptysis who was diagnosed to have IMT. Resection of the tumour was done with the help of rigid bronchoscopy. Post-resection, hemoptysis stopped and no recurrence of tumour was noted on subsequent follow-up. We also present a systematic review of literature of all the cases of tracheo-bronchial IMT treated with bronchoscopic resection and conclude it to be a useful alternative to surgery in such cases.

Cystic lung disease in tuberculosis: An unusual presentation.

Cysts in the lung can arise due to large number of causes out of which tuberculosis is very rare, We report a case of tuberculosis in a young female presenting as a febrile illness and respiratory failure with radiological features of cystic lung disease. With treatment,fever and respiratory distress subsided and cysts in the lungs showed partial regression. We highlight the need to consider tuberculosis in the differential diagnoses of cystic lung disease under appropriate circumstances.

Rifampicin induced adrenal crisis in an uncommon setting.

Adrenal crisis occurs when there is decreased secretions of steroid hormones (mainly cortisol) from the adrenal glands due to varied reasons. It may arise due to a primary adrenal condition or due to decreased hormonal signals from the pituitary secondary to a hypofunctioning pituitary. Hypopituitarism may result due to direct causes like trauma, tumour, infection or it may be due to some vascular insult as seen in Sheehan syndrome. We report an unusual presentation of Sheehan syndrome in the form of life-threatening adrenal crisis precipitated by the usage of rifampicin.

Uvulopalatopharyngoplasty - surgery for snoring.

Snoring is a social problem and is considered to be a warning sign, in relation to the upper airway structural and physiological anatomy. The complications and sequelae of snoring can be life threatening also. Therefore it becomes important to treat snoring in the first instance. Surgical treatment of snoring is the standard protocol (UPPP) Uvulopalatopharyngoplasty, was started by Fujita a and this technique has now been found to be very effective. 8 cases of snoring with no evidence of sleep apnta were operated in the department with a standard modified technique. The technique und the results are discussed here.

Therapeutic bronchoscopy.

Endoscopic therapy has been used extensively in every field of medicine. The bronchial tree is no exception. The rigid bronchoscope was mainly used for foreign body extraction and hemostasis from and in the bronchial tree. With the evolution of flexible fiberoptic bronchoscope, the scope of therapeutic bronchoscopy has widened. The principles of therapeutic bronchoscopy, the various indications and brief description of such procedures like laser-bronchoscopy, endo-bronchial brachytherapy, management of airway strictures, its role in management of hemoptysis and foreign body removal have been reviewed.

The protocol for the diagnosis of obstructive sleep apnea syndrome.

Our understanding of the nature and the sequence of upper airway obstruction has evolved gradually but considerably. This obstruction, occurring repeatedly in sleep alongwith daytime sleepiness is called Sleep Apnea Syndrome. Narrowing or closures may occur at one or more sites in an unstable upper airway. The upper airway size is determined by soft-tissue and skeletal factors, that are also major determinants of upper airway patency during sleep. The presence of certain physical characteristics should strengthen the surgeons suspicion of some dysfunction during sleep. There are various methods of identifying the physical attributes in patient of Sleep Apnea. The measurement of all the characters plus the sleep study, helps the surgeon eventually to select the site needing immediate treatment. This will not only straighten the upper airway but also prevent any re-occurrences, which is very common if the patient is not properly evaluated. Great stress should be laid on presurgical protocol, an alternative for more appropriate diagnosis and treatment.

Antrochoanal polyp-a cause of obstructive sleep apnoea in children.

Obstructive sleep apnoea syndrome is a well established entity which has received much attention in the recent past. In children the commonest cause of sleep apnoea is adenotonsillar hypertrophy. We report two cases of antrochoanal polyp in children who presented with symptoms consistent with sleep apnoea. Preoperative polysomnography was performed in these cases which confirmed the diagnosis of sleep apnoea. Under general anaesthesia both children underwent polypectomy with middle meatal antrostomy Post operatively the patients were put on steroid nasal spray for 2 weeks. Repeat polysomnograpy performed four weeks following surgery revealed reversal ot disturbed sleep patterns.

Comparison of pleural fluid cytology and pleural biopsy in the evaluation of pleural effusion.

Pleural fluid cytology and pleural biopsy results were studied in 65 cases of pleural effusion. The efficacy of pleural biopsy in diagnosis of neoplastic and non-neoplastic pleural diseases was compared. Of the 24 cases with confirmatory evidence of cancer, 17(70.8%) has positive cytologic findings in pleural fluid, whereas pleural biopsy was diagnostic in only 13 cases (54.1%). For non-malignant pleural effusion in 41 cases 40(97.5%) has a definite diagnosis (tuberculous pleuritis, acute fibrinous pleuritis or hydatid cyst) which could be made by cytology while only 31(75.6%) out of 41 were diagnosed on pleural biopsy. The study indicates that cytologic evaluation of pleural fluid is more efficaceous in the diagnosis of malignant and non-malignant pleural disease than percutaneous pleural biopsy.

A study of bronchial reactivity in relation to baseline pulmonary functions in patients with chronic obstructive lung disease.

Baseline bronchial reactivity was studied in 36 patients with chronic obstructive lung disease (COLD) and 20 normal healthy controls using the inhalational histamine challenge test. Using a cut off PD20 dose of 0.195 mg of histamine, 83.3% patients of COLD demonstrated bronchial hyper-reactivity. Presence of bronchial reactivity correlated significantly with the baseline FEV1, FEF25-75 and the ratio FEV1/FVC (p = 0.0019, 0.00001 and 0.008) respectively. Thus, bronchial reactivity in subjects with COLD correlates most significantly with the maximum mid-expiratory flow rate (FEF25-75).

Evaluation of unguided transbronchial biopsy in the diagnosis of pulmonary disease--its safety and efficacy as an out-patient procedure.

Sixty-five patients underwent unguided fiberoptic transbronchial biopsy on an out-patient basis. Satisfactory material for histopathological examination was obtained in 55 patients. A reasonably definite pathological diagnosis could be established in 51 patients. The commonest diagnosis arrived at was that of interstitial fibrosis. Complications were observed in 4 (6.2%) patients. Fiberoptic transbronchial biopsy is, therefore, a safe and efficacious out-patient technique for establishing a pathological diagnosis in patients with infiltrative, diffuse or localized pulmonary disease.

Role of corticosteroids in the management of chronic obstructive lung disease: factors predicting response.

A double-blind crossover trial of prednisolone was conducted in 70 patients of chronic obstructive lung disease (COLD). Emphysema dominated the clinical picture in 38, rest being chronic bronchitis with varying degrees of air trapping. None of the patients had clinical asthma. All the patients had obtained maximal benefit from an optimal dose of bronchodilators prior to entering the study. Prednisolone in a dose of 0.8 mg/kg was prescribed in a double blind crossover manner with identical appearing placebo tablets. Patients were evaluated on a weekly basis for an objective as well as a subjective response and side effects of therapy. Thirty-four patients demonstrated a statistically significant improvement in pulmonary functions. In 20 others only subjective response was observed. A good objective response was predicted by a pre-study variability in FEV1, disease duration of less than 10 years and a history of smoking less than 50 pack years.

Safety and efficacy of unguided trans thoracic fine needle aspiration biopsy (FNAB) in outdoor patients.

We studied the safety and efficacy of unguided transthoracic fine needle aspiration biopsy (FNAB) in peripheral lung lesions in an outpatient setting in 62 patients. The diagnostic yield of unguided aspiration was 67.7 per cent. Smaller lesions usually required guided FNAB. Specific tissue diagnosis was obtained in all cases aspirated successfully. Complications were seen in 7 patients (pneumothorax in 4 and haemoptysis in 3 patients). With careful patient selection, unguided FNAB can be an effective out-patient procedure for diagnosing lung lesion beyond the reach of the fiberoptic bronchoscope.

Role of serial pleural biopsies in the diagnosis of pleural effusions.

One hundred fifty-five cases of pleural effusion underwent a percutaneous pleural biopsy by the Cope needle. In the face of an inconclusive result in the first attempt, biopsy was repeated for upto three times. Diagnostic yields of biopsy in tuberculous and malignant effusion were 93.5 per cent and 66.7 per cent, respectively. When combined with pleural fluid cytology, a definite diagnosis of malignancy could be established in 80.95 per cent cases. Serial pleural biopsies significantly increased the diagnostic yield.

Efficacy of adenosine deaminase in the diagnosis of pleural effusions.

Adenosine deaminase (ADA) activity was studied in 53 patients with pleural effusions. Patients with tuberculous pleural effusion (36) had significantly higher ADA activity (77.68 IU/L; P less than 0.001) in comparison to malignant (14.47 IU/L) and parapneumonic (28.65 IU/L) effusions. When tested with a reference limit of over 50.75 IU/L, the specificity of ADA activity was found to be 94.1 per cent. With a sensitivity of 100 per cent, low cost and easy performance pleural fluid ADA activity is proposed as a routine investigation for etiological diagnosis in pleural effusion.

Cryptogenic hemoptysis: role of fiberoptic bronchoscopy.

Fiberoptic bronchoscopy (FOB) was performed for recurrent hemoptysis in 79 patients with normal chest roentgenograms. Seventy per cent were females with a mean age of 31.93 years. Normal findings were obtained in 60 patients. In 19 patients with abnormal findings on bronchoscopy underlying malignant disease was discovered in 3 patients following bronchoscopy. All these patients were elderly male smokers. In three patients unexplained left recurrent laryngeal nerve palsy was discovered. Thus, FOB as a diagnostic aid for cryptogenic hemoptysis is useful only in elderly male smokers.

Clinical and roentgenological profiles and etiological correlations of encysted pleural effusions.

One hundred and thirty-six cases of encysted pleural effusions were studied and investigated to reach an etiological diagnosis. The clinical profile of encysted pleural effusions differed little from that of free pleural effusions. Of the four sites of encystments seen (costoparietal, interlobar, subpulmonic, and mediastinal), costoparietal effusions were the commonest and resulted most often from infections. Interlobar encystments came next in frequency and most often resulted from congestive cardiac failure. Of the various causes of encysted pleural effusions, tuberculosis was the commonest, followed by pyogenic infection and congestive cardiac failure, in this order. Conventional radiographic techniques were adequate in diagnosing most cases of encysted pleural effusions.