Experience with treatment of pulmonary alveolar proteinosis from a tertiary care centre in north India.

Background. Pulmonary alveolar proteinosis (PAP) is a disorder characterised by accumulation of lipids and proteins in the alveoli, with the resultant symptoms ranging from indolent subclinical disease to progressive respiratory failure. Methods. We retrospectively studied five patients with PAP managed at our center between January 2007 and April 2010, with whole lung lavage (WLL) and/or subcutaneous granulocyte macrophage-colony stimulating factor (GM-CSF) therapy. Patients undergoing WLL under general anaesthesia were supplemented with three months of GM-CSF therapy. Pre- and post-lavage symptom assessment was performed with a 10-point, symptom-based visual analogue scale. Results. Their mean age was 37.6±7.0 years; there were four males. Diagnosis of PAP [idiopathic (n=3); secondary to Nocardia (n=1)] was established by surgical lung biopsy in four patients who presented with respiratory failure. Three patients with idiopathic PAP (n=3) were treated with a combination of GM-CSF and WLL; one patient with secondary PAP was treated with antibiotics alone. In another patient transbronchial lung biopsy was used to diagnose PAP and GM-CSF alone was administered. All patients were followed up for a median period of two years (range 0.5-3 years). Significant improvement was achieved in all the patients with therapeutic WLL and/or GM-CSF. Conclusions. Whole lung lavage appeared to be an effective and safe therapy in patients with PAP. Efficacy of simultaneous administration of GM-CSF and WLL in the treatment of PAP merits further study.

Initial experience of endobronchial silicon stents from a tertiary care centre in north India.

Background. Central airway obstruction (CAO) is defined as obstruction of trachea and principal bronchi. Therapeutic rigid bronchoscopy with tracheobronchial stenting using silicon stents is a well established procedure in the management of such conditions. However, there is limited experience with this technique in India. Methods. Between January 2010 and April 2010, Dumon stents were placed in four patients with CAO. Three patients had symptomatic tracheal stenosis while one patient had malignant obstruction at the carina. Rigid bronchoscopy under general anaesthesia was performed to relieve the CAO followed by placement of silicon stents. Pre- and post-stent placement symptom assessment was performed with a symptom-based visual analogue scale. Results. Four patients underwent silicon stent placement in the tracheobronchial tree. Three patients had benign postintubation tracheal stenosis and one had malignant tracheal obstruction at carina due to endobronchial growth. Significant improvement was achieved in all patients. There were no significant complications. Conclusions. Rigid bronchoscopy with silicon stent placement is an effective and suitable method of relieving the distressing symptoms due to benign or malignant airway obstruction.

Immune responses to mycobacterial antigens in sarcoidosis: A systematic review.

From the time sarcoidosis has been described, there has always been a viewpoint that the disease is in some way related to tuberculosis (TB). Sarcoidosis is a granulomatous disease, which is likely a result of continued presentation of a poorly degradable antigen. Mycobacterium tuberculosis has been a very strong contender for this antigen. Besides the molecular studies demonstrating mycobacterial deoxyribonucleic acid (DNA) in the sarcoid tissue, assessment of immune responses against mycobacterial antigens provides a useful tool to study the role of mycobacteria in the pathogenesis of sarcoidosis. We reviewed the studies focussing on T-cell and B-cell responses to tubercular antigens in patients with sarcoidosis. Pooled data from various studies does provide a suggestive, though not unequivocal evidence in favour of mycobacteria as a cause of sarcoidosis. These findings not only reinforce the possible pathogenic role of mycobacterial antigens in sarcoidosis, but at the same time also limit the clinical utility of molecular and serological studies based on mycobacterial antigens in the differential diagnosis of TB from sarcoidosis, particularly in a country with high endemicity for TB.

Medical thoracoscopy for undiagnosed pleural effusions: Experience from a tertiary care hospital in north India.

Background and Aims. Medical thoracoscopy, also called pleuroscopy, has received renewed interest in the recent past for diagnostic as well as therapeutic uses. In this study, we describe our experience with thoracoscopy for undiagnosed pleural effusions. Methods. In a retrospective analysis of thoracoscopic procedures we performed between January 2007 and December 2008, yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleural effusions with adenosine deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy on three occasions was evaluated. Complications of thoracoscopy were also analysed. Results. Overall diagnostic yield of thoracoscopic pleural biopsy was 74.3% in patients with undiagnosed pleural effusions. Pleural malignancy was diagnosed in 48.6% of patients. There was only one case of mesothelioma and the rest were due to pleural metastasis. Lung cancer and breast cancer were the most common sites of primary malignancy. Tuberculosis was diagnosed with pleural biopsy in 22.8% of patients. We had low complication rate after thoracoscopy. Only two cases of empyema were observed. Conclusion. Medical thoracoscopy is a safe procedure and has good diagnostic yield in patients with undiagnosed pleural effusions.

Prevalence and risk factors for bronchial asthma in Indian adults: a multicentre study.

BACKGROUND: There is limited information on field epidemiology of bronchial asthma in Indian adults. OBJECTIVES: To estimate prevalence of bronchial asthma in different regions of India and to define risk factors influencing disease prevalence. METHODS: A field study was conducted at Chandigarh, Delhi, Kanpur and Bangalore through a two stage stratified (urban/ rural) sampling and uniform methodology using a previously validated questionnaire. Asthma was diagnosed if the respondent answered affirmatively both to (a) whistling sound from chest, or chest tightness, or breathlessness in morning, and (b) having suffered from asthma, or having an attack of asthma in the past 12 months, or using bronchodilators. Besides demographic data, information on smoking habits, domestic cooking fuel used, atopic symptoms, and family history suggestive of asthma was also collected. Univariate and multivariate logistic regression modelling was performed to calculate odds ratio of various potential risk factors. RESULTS: Data from 73605 respondents (37682 men, 35923 women) were analysed. One or more respiratory symptoms were present in 4.3-10.5% subjects. Asthma was diagnosed in 2.28%, 1.69%, 2.05 and 3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore, with overall prevalence of 2.38%. Female sex, advancing age, usual residence in urban area, lower socio-economic status, history suggestive of atopy, history of asthma in a first degree relative, and all forms of tobacco smoking were associated with significantly higher odds of having asthma. CONCLUSION: Prevalence estimates of asthma in adults in this study, although lower than several previously reported figures, point to a high overall national burden of disease.

A multicentric study on epidemiology of chronic obstructive pulmonary disease and its relationship with tobacco smoking and environmental tobacco smoke exposure.

INTRODUCTION: Population prevalence of chronic obstructive pulmonary disease (COPD) and its relationship with tobacco smoking, environmental tobacco smoke (ETS) exposure and other variables were studied in adult subjects of 35 years and above at four different centres in India. Question-items for the diagnosis of COPD were included in the questionnaire used for the field study on asthma epidemiology. METHODS: Field surveys were conducted in both the urban and the rural populations at Bangalore, Chandigarh, Delhi and Kanpur with the help of a structured and validated questionnaire for diagnosis of asthma and COPD. Separate sets of questions were used for the diagnoses of the two diseases. A two-stage stratified sample design was employed where a village or an urban locality formed the first stage unit and a household formed the second stage unit. A uniform methodology was used at all the four centres and the analyses were done at the central coordinating centre--Chandigarh. Chronic obstructive pulmonary disease, defined by chronic bronchitis (CB) criteria, was diagnosed from the presence of cough and expectoration on most of the days for at least three months in a year for two consecutive years or more. RESULTS: Chronic obstructive pulmonary disease was diagnosed in 4.1% of 35295 subjects, with a male to female ratio of 1.56:1 and a smoker to nonsmoker ratio of 2.65: 1. Prevalence among bidi and cigarette smokers was 8.2% and 5.9%, respectively. Odds ratio (OR) for COPD was higher for men, elderly individuals, lower socio-economic status and urban (or mixed) residence. Environmental tobacco smoke exposure among nonsmokers had an OR of 1.4(95% CI 1.21-1.61). Combined exposure to both ETS and solid fuel combustion had higher OR than for ETS exposure alone. CONCLUSIONS: Population prevalence of COPD is very high in India with some centre to centre differences. Smoking of both bidis and cigarettes, and ETS exposure among nonsmokers, were two important risk factors at all centres. It is important to employ uniform methodology for assessment of national burden and disease-surveillance programme.

Household environmental tobacco smoke exposure, respiratory symptoms and asthma in non-smoker adults: a multicentric population study from India.

BACKGROUND: Exposure to environmental tobacco smoke (ETS) is a risk factor for childhood asthma. Its association with asthma in adults is less clear. METHODS: In a multicentric population study on asthma prevalence in adults, specific enquiries were made into childhood and adulthood exposure to household ETS, and its relationship with asthma diagnosis were analysed. RESULTS: From a total of 73605 respondents, 62109 were studied after excluding current or past smokers. Overall observed prevalence of asthma was 2.0% (men 1.5%,women 2.5%, p < 0.001). Of all asthma patients, history of ETS exposure was available in 48.6 percent. Prevalence of asthma in the ETS exposed subjects was higher compared to non-exposed individuals (2.2% vs 1.9%, p < 0.05). Multiple logistic regression analysis showed a higher risk of having asthma in persons who were exposed to ETS compared to those not exposed (odds ratio [OR] 1.22, 95% CI 1.08-1.38) after adjusting for age, gender, usual residence, exposure to biomass fuels and atopy. Stratification of ETS exposure revealed that exposure during childhood and both during childhood and adulthood were significantly associated with asthma prevalence. Exposure only in adulthood was not a significant risk factor (OR 1.13, 95% CI 0.95-1.33). Persons reporting combined environmental tobacco smoke exposure from parents during childhood and spouse during adulthood had highest risk of having asthma (OR 1.69, 95% CI 1.38-2.07). Environmental tobacco smoke exposure was also significantly associated with prevalence of respiratory symptoms such as wheezing, cough and breathlessness. CONCLUSIONS: Environmental tobacco smoke exposure during childhood is an important risk factor for asthma and respiratory symptoms in non-smoking adults.

Tobacco smoking in India: prevalence, quit-rates and respiratory morbidity.

BACKGROUND: Population prevalence of tobacco smoking especially with reference to detailed habits such as the amount smoked, the smoking forms, quit-rates and relationship with demographic variables were studied at four different centres in India along with the study on epidemiology of asthma and chronic obstructive pulmonary disease. METHODS: The study population included adults of over 15 years of age selected with two-stage stratified random sample design. A specifically designed questionnaire was used for the study. RESULTS: There were 11496 (15.6%) ever smokers in the study sample of 73605 subjects. Among 37682 males, 10756 (28.5%) were ever smokers and among 35923 females, 740 (2.1%) were ever smokers. Bidi was the commonest form of smoking, more so in the rural areas. The mean number of cigarettes/bidis smoked per day was 14 (+/- 11.5) and the mean age of starting smoking was 20.5 (+/- 20.0) years. Increasing age, low socio-economic status and rural residence were important factors associated with smoking. Vigorous anti-tobacco measures under the tobacco control programmes yielded only a quit-rate of 10 percent. Nearly 14% of ever smokers had some respiratory symptoms. CONCLUSIONS: A substantial proportion of population in India has current or past smoking habit with higher prevalence among males than females. The quit-rates have been low in spite of the various anti-tobacco measures. There is a significant respiratory morbidity associated with smoking.

Noninvasive estimation of clinically asymptomatic pulmonary hypertension in idiopathic pulmonary fibrosis.

OBJECTIVES: To determine the prevalence of pulmonary hypertension in patients with idiopathic pulmonary fibrosis (IPF) by noninvasive methods. PATIENTS AND METHODS: Twenty seven patients with IPF attending the Chest Clinic over a period of one-and-a-half-years underwent echocardiography for evidence of pulmonary hypertension, which was defined as pulmonary artery systolic pressure > or = 40 mmHg by Doppler echocardiography, or pulmonary acceleration time < or = 100 milliseconds or two-dimensional echocardiographic findings of right ventricular hypertrophy or overload. RESULTS: Two patients with clinical evidence of pulmonary hypertension were excluded from analysis. Their mean age (n = 25) was 53.8 years. The mean duration of symptoms before presentation was 2.1 years. Pulmonary hypertension was diagnosed by echocardiography in nine of the 25 patients (36%). There was a statistically significant difference between the duration of illness, arterial oxygen tension (PaO2) levels and forced vital capacity in patients with pulmonary hypertension than in those without pulmonary hypertension. Logistic regression analysis showed a significant association between the duration of illness, decreasing forced vital capacity and hypoxemia with the development of pulmonary hypertension. CONCLUSIONS: Echocardiography detects pulmonary hypertension in clinically asymptomatic individuals, and should be used routinely for the diagnosis of pulmonary hypertension in patients with IPF.

Applicability of commonly used Caucasian prediction equations for spirometry interpretation in India.

BACKGROUND & OBJECTIVE: The applicability of Caucasian prediction equations in interpreting spirometry data in Indian patients has not been studied. The present study was undertaken to see if Caucasian and north Indian prediction equations can be used interchangeably while interpreting routine spirometric data. METHODS: Forced vital capacity (FVC), forced expiratory volume in first second (FEV(1)), and FEV(1)/FVC ratio were recorded from 14733 consecutive spirometry procedures in adults. Predicted values and lower limits of normality were calculated using regression equations previously derived at this centre, and four commonly used Caucasian equations described by Knudson, Crapo, European Community for Coal and Steel (ECCS) and the Third National Health and Nutrition Examination Survey (NHANES III). For men, 90 per cent of predicted values were also derived. Kappa estimates were used to study agreement, and Bland Altman analysis was performed to quantify differences, between interpretations from Indian and Caucasian equations. Receiver operating characteristic (ROC) curves were constructed to assess utility of using a fixed percentage of Caucasian predicted values in categorizing FVC or FEV(1) as abnormal. RESULTS: The use of Caucasian prediction equations (and 90% of predicted values in men) resulted in poor agreement with Indian equation in most height and age categories among both men and women. Bland Altman analysis revealed a large bias and wide confidence limits between Caucasian and Indian equations, indicating that the two cannot be used interchangeably. ROC analysis failed to yield good results with use of any single fixed percentage of Caucasian predicted value while categorizing FVC or FEV(1). INTERPRETATION & CONCLUSION: Our results showed that the use of Caucasian prediction equations, or a fixed percentage of their predicted values, resulted in misinterpretation of spirometry data in a significant proportion of patients. There is a need to assess performance of more than one regression equation before choosing any single prediction equation.

Prevalence of tobacco use among school going youth in North Indian States.

BACKGROUND: Tobacco use, which is the cause of several respiratory diseases, generally starts in the teens. Global Youth Tobacco Survey (GYTS) is an international initiative to investigate the tobacco use in school going youth of 13 to 15 years of age. This report describes the GYTS findings in the North Indian region. METHODS: A two-stage cluster sample was used with selection of schools on probability proportional to enrollment size followed by systematic equal probability sampling with a random start of classes from each school. The 85-item questionnaire included 'core GYTS' and other additional questions. Data analysis was performed using EpiInfo 3.2 software and the results accounted for the complex sampling design and weighting factors in the data set. RESULTS: The sample consisted of 9319 students out of the total eligible population of 30488 from 100 schools. The prevalence of ever-use of tobacco varied between 2.9 to 8.5% in boys and 1.5 to 9.8% in girls. The prevalence was highest in Chandigarh and lowest in Punjab. Between 16 to 46% of students were exposed to the habit of tobacco among parents or friends. There were 10 to 34% students who were passively exposed to environmental tobacco smoke. CONCLUSION: Tobacco use is present in up to 10 percent of school going youth in the region. A majority of them had desired to quit. Tobacco control and cessation programmes therefore, remain important health issues.

Profile of repeat fiberoptic bronchoscopy.

BACKGROUND: Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of pulmonary diseases, but in many instances the procedure has to be repeated because of an inconclusive initial FOB or for reassessment. METHODS: A retrospective analysis of all the fiberoptic bronchoscopic procedures done between September 2000 and February 2003 was performed and details of patients undergoing repeat FOB abstracted. RESULTS: Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated, yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in 112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The major indications for repeating FOB included obtaining specimens for pathological examination, pre and postoperative evaluation of airways, localization of site of bleeding in patients with hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results, either in form of positive histology or localisation of source of hemoptysis. CONCLUSIONS: The frequency of repeat bronchoscopy was low. Commonest indication for a repeat procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield positive results even when the initial FOB is nondiagnostic.

Excess morbidity and expenditure on healthcare in families with smokers: a community study.

BACKGROUND: There is paucity of information on health-related expenditure attributed to smoking in India. This community study estimated the expenditure on healthcare and morbidity borne by families of smokers and compared these with those of families without smokers. It was hypothesized that families with smokers were likely to have a higher health expenditure than non-smoker families attributable to the increased probability of health problems associated with smoking. METHODS: The study population comprised 1000 urban and rural families divided into two groups. Group I consisted of 500 families with one or more smoker(s) while group II comprised 500 families without a smoker. Both groups had an equal representation from the urban and rural populations (250 each). The study team used a structured, generally close-ended questionnaire, pre-tested for its validity and reliability, to interview the families. Different components of health-related expenditure and other morbidity indices were studied. Each family was studied in two phases: (i) initially, for the retrospective assessment of expenditure and other losses during the preceding one year, and (ii) prospectively, for the following 10 months on repeated visits and estimations made every two months. The data collected retrospectively were mostly incomplete and could not be used for analyses. RESULTS: The number of family members reporting sick was significantly higher in group I than in group II among both urban and rural families (p < 0.001). There was an excess expenditure of Rs 730 and Rs 141, in addition to Rs 4209 and Rs 894 on smoking products in group I families in urban and rural areas, respectively. Univariate analysis showed that the odds ratio for having any health-related expenditure for a group I family was 3.346 (95% confidence interval 2.533-4.420), which was highly significant (p < 0.0001). The differences in loss of work on account of illness and loss of man-days among members of groups I and II were not significant. However, the number of lost school days among children of group I families, loss of efficiency of its members and change of jobs due to loss of efficiency were highly significant. CONCLUSION: The direct healthcare costs as well as the indirect fiscal losses are higher in families with one or more smoker(s).

Development of a computer software for easy storage and analysis of fibreoptic bronchoscopy data.

OBJECTIVE: To develop a simple software for management of fibreoptic bronchoscopy records. METHODS: After identification of the specific needs at our hospital, a software was developed. A graphical interface with structured data entry related to patient information and diagnosis, bronchoscopic findings and specimens obtained, and their reports were envisaged. After initial construction, the software was tested over a four-week period. The software was put to routine use after necessary corrections, and validated over the next few months through actual data entry. RESULTS: The software has various modules for input and modification of data, as well as for generation of reports, and can work both on stand-alone personal computers and on networks. With little practice, residents soon became adept at entering details correctly and quickly. The slightly increased time of data entry into the computer was more than made up by uniform and complete report generation. The database component was evaluated by analyzing 1000 consecutive records entered over a 14-month period, and no discrepancies were observed. CONCLUSION: A user-friendly software providing uniform and complete data entry regarding fibreoptic bronchoscopic procedures was developed.

Bronchial hyperresponsiveness in patients with sarcoidosis.

OBJECTIVE: To study bronchial hyperresponsiveness (BHR) in patients with sarcoidosis. METHODS: Twenty freshly diagnosed patients with sarcoidosis were evaluated. Progressively increasing concentrations of methacholine were administered using a standard five-breath dosimeter protocol, and spirometry performed after each challenge. BHR was expressed as PC20 (provocating concentration of methacholine resulting in 20% fall in forced expiratory volume in first second). All patients were nonsmokers, had no other concurrent cardiopulmonary disease, and were not on any specific treatment for sarcoidosis. RESULTS: Borderline (PC20 4.0-16.0 mg/mL), mild (PC20 1.0-4.0 mg/mL) and moderate to severe (PC20 <1.0 mg/mL) BHR was documented in three (15%), one (5%) and five (25%) patients respectively. Patients with BHR were similar to those having normal reactivity in terms of age, gender, disease duration and results of pulmonary function testing. All patients with endobronchial disease had BHR. CONCLUSION: BHR may be seen in several patients of sarcoidosis and could possibly contribute to decline in lung function.

Ifosfamide containing regimen for non-small cell lung cancer.

BACKGROUND: Combination chemotherapy has been demonstrated as one of the best active regimens in patients with non-small cell lung cancer (NSCLC). METHODS: A total of 206 patients with advanced unresectable NSCLC stage III B or stage IV were enrolled to receive combination chemotherapy with mitomycin, ifosfamide and cisplatin. About a third of them (n=63) did not continue therapy after the first course either because of toxicity, lack of affordability, or death. The remaining 143 patients (121 males) received two or more cycles of chemotherapy. RESULTS: Nearly half of all followed-up patients showed a partial or complete radiological response. Overall performance status (Karnofsky scale) worsened in 28 (19.6%) and improved in 44 (30.8%). While 50 patients (35%) gained weight, 65 (45.5%) lost weight during follow-up. Overall median survival was 20 weeks [95% confidence interval (CI), 16 to 24 weeks]. However, overall survival improved progressively with the number of chemotherapy cycles administered. Median survival in patients receiving at least three, four and five chemotherapy cycles was 23 (95% CI, 19-27); 27 (95% CI, 24-30) and 35 (95% CI, 28-42) weeks respectively. Survival at the end of three, six, nine and 12 months was 64.3%, 29.4%, 14.7% and 9.8%) respectively. Survival had no association with age of the patient, but was significantly correlated with baseline performance status (Pearson's correlation coefficient 0.29 p<0.01). The cost of each course of chemotherapy was a little over 100 US dollars. The side effects were minimal and acceptable, and the regimen was tolerated well by all the patients. CONCLUSION: Ifosfamide regimen containing mitomycin and cisplatin is a chemotherapeutic combination for treating patients with advanced NSCLC.

Spectrum and diagnosis of idiopathic pulmonary fibrosis.

OBJECTIVE: To study the clinical profile of patients with idiopathic pulmonary fibrosis (IPF) and methods used for diagnosis. METHODS: Prospective analysis of symptoms, signs, radiology and lung biopsy of patients freshly diagnosed to have IPF over a 16-month period. RESULTS: During the study period, 76 patients (35 men) with a mean age of 50.6 +/- 11.9 years were diagnosed to have IPE Breathlessness (98.6%) and dry cough (92.1%) were the most common presenting symptoms. Transbronchial lung biopsy (TBLB) was performed in 38 (50%) patients. Histopathological examination revealed features consistent with IPF in 35 (92.1%) patients; two of the remaining three patients underwent open lung biopsy. Other patients were diagnosed based on clinical features and high resolution chest tomography (HRCT) findings. HRCT was performed in 69 (90.8%) patients; all had features suggestive of diffuse interstitial fibrosis. CONCLUSION: IPF is diagnosed more commonly now than in the past. Indian patients may be developing the disease a decade earlier than their counterparts in the West. TBLB and HRCT are useful in establishing diagnosis. IPF should be considered a distinct clinical entity rather than a diagnosis of exclusion.

Effect of household exposure to environmental tobacco smoke on airflow mechanics in asymptomatic healthy women.

BACKGROUND & OBJECTIVES: Exposure to environmental tobacco smoke (ETS) can lead to airflow limitation, similar to that seen in smokers. However, the effects have not been conclusively proven. In the present study an attempt was made to characterize the effect of ETS exposure at home on airflow mechanics in asymptomatic healthy women. METHODS: Fifty women volunteers with no apparent health related problem, exposed to household ETS (group I), and 50 age-matched women not exposed (group II) were studied. Vital capacity (VC), forced expiratory flow in first second (FEV1), FEV1/VC ratio, peak expiratory flow (PEF), maximal midexpiratory flow (FEF(25-75%)), airway resistance (R(aw)) and specific airway conductance (sG(aw)) were measured, and compared between the two groups. Conditional logistic and linear regression analysis were done to assess contribution of household ETS exposure to decreased lung function. RESULTS: FEV1 and PEF values were marginally lower among women in group I (mean difference 0.13 l and 0.20 l/sec respectively). FEF(25-75%), R(aw) and sG(aw) were significantly impaired in this group. Ten (20.0%) women in group I and five (10.0%) in group II had abnormal R(aw) (adjusted odds ratio 6.72, 95% confidence limits 1.15-39.42), while eight (16.0%) women in group I and one (2.0%) in group II had abnormal sG(aw) (adjusted odds ratio 21.08, 95% confidence limits 1.30-341.05). Cumulative life time ETS exposure was, not significantly related to a reduction in FEV1, VC, PEF, FEF(25-75%), R(aw) or sG(aw) after adjustments for potential confounders. INTERPRETATION & CONCLUSION: Exposure to household ETS resulted in subtle impairment of airflow mechanics in asymptomatic women, possibly attributed to small airway narrowing. Further investigations are required to study the progression of this impairment with time.