Unilateral Presentation of Pulmonary Alveolar Proteinosis

Pulmonary alveolar proteinosis (PAP) is a rare disorder, in which lipoproteinaceous material accumulates within the alveoli. We report a case of a 27-year-old male patient with acute worsening of breathlessness over the last 7�months and cough with desaturation up to 79% on room air. Contrast-enhanced computerized tomography of the thorax revealed unilateral diffuse crazy-paving pattern likely PAP. Transbronchial lung biopsy confirmed the diagnosis of PAP. The present case highlights the unusual presentation of PAP with unilateral involvement. To the best of our knowledge, this is the first reported case of unilateral PAP from India with a biopsy diagnosis and resolution with whole lung lavage.

Relationships between self-reported dyspnea, health conditions and frailty among Brazilian community-dwelling older adults: a cross-sectional study

ABSTRACT CONTEXT: Dyspnea is a symptom present in several chronic diseases commonly seen among older adults. Since individuals with dyspnea tend to stay at rest, with consequently reduced levels of physical activity, they are likely to be at greater risk of developing frailty, especially at older ages. DESIGN AND SETTING: Cross-sectional study at community level, Brazil. OBJECTIVE: To analyze the relationships between self-reported dyspnea, health conditions and frailty status in a sample of community-dwelling older adults. METHOD: Secondary data from the follow-up of the Frailty in Brazilian Elderly (FIBRA) study, involving 415 community-dwelling older adults (mean age: 80.3 ± 4.68 years), were used. The variables analyzed were sociodemographic characteristics, reported dyspnea, clinical data and frailty phenotype. Associations between dyspnea and other variables (age, sex, education and body mass index) were verified through the crude (c) and adjusted (a) odds ratios. RESULTS: The prevalence of dyspnea in the entire sample was 21.0%. Dyspnea was more present in individuals with pulmonary diseases, heart disease, cancer and depression. Older adults with multimorbidities (adjusted odds ratio, ORa = 2.91; 95% confidence interval, CI = 1.41-5.99) and polypharmacy (ORa = 2.02; 95% CI = 1.15-3.54) were more likely to have dyspnea. Those who reported dyspnea were 2.54 times more likely to be frail (ORa = 2.54; 95% CI = 1.08-5.97), and fatigue was their most prevalent phenotype component. CONCLUSION: Dyspnea was associated with different diseases, multimorbidities, polypharmacy and frailty. Recognizing the factors associated with dyspnea may contribute to its early identification and prevention of its negative outcomes among older adults.

Study of clinical, radiological, and pulmonary function characteristics of patients having asthma-chronic obstructive pulmonary disease overlap syndrome

Background: Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome defined as a syndrome characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. This overlap makes the difference between COPD and asthma with persistent airflow limitation difficult, especially in smokers and elderly people. Objective: The objective of the study was to study the clinical features, radiological and pulmonary function characteristics of patients having asthma-COPD overlap syndrome. Materials and Methods: A cross-sectional study carried out at the Department of Respiratory Medicine, Government Medical College, Baroda, attached to SSG Hospital, Vadodara. A total of 100 patients enrolled which were clinically diagnosed with chronic airway obstruction as defined in the GOLD/GINA asthma-COPD overlap syndrome (ACOS) guidelines. Results: In this study, a total of 100 patients were enrolled, out them 76 patients were male and 24 patients were female. Fifty-three patients were from urban area and 47 patients from rural area. Most patients belong to age ranging from 40 to 86. Ninety-nine patients had a breathlessness and it was the most common symptom followed by chronic cough in 93 patients, sputum production in 70 patients, wheezing in 70 patients, running nose in 65 patients, and chest tightness in 46 patients. In smoking history, 25 patients were current smoker, 49 patients were ex-smoker, and 26 patients had never smoked in their life. In pulmonary function test, 26 patients had a normal test, 13 patients had obstructive abnormality with no significant bronchodilator reversibility, 54 patients had a obstructive abnormality with significant bronchodilator reversibility, and 7 patients had a restrictive abnormality. Conclusion: Clinically diagnosed ACOS patients were mostly males, belong to middle age groups, had breathlessness, wheezing, chronic cough with sputum production, and rhinitis and sneezing as the major symptoms. The pulmonary function tests revealed majority of the patients having obstructive pattern in pulmonary function test (spirometry). Furthermore, a majority of these patients had significant positive bronchodilatory response.

An interesting case report of ruptured pyogenic liver abscess with 40 weeks gestation in labour

Pyogenic liver abscess during pregnancy is an extremely rare condition. Although rare, in situations of sepsis or septic shock in pregnancy, as well as the common sources of infection, a possibility of a liver abscess should be considered. We present a case report of 32-year-old primigravida 37.3 weeks by date, 37 weeks by scan with breech presentation with premature rupture of membranes and pain in abdomen since 12 hours with breathlessness, fever and diarrhoea since 2 days came in emergency to study hospital. General condition of the patient on arrival was pulse-140 beats per minute, blood pressure was 90/60 mmHg, respiratory rate was 40/min, on per abdominal examination, breech presentation with fetal heart rate of 150 beats per minute on doppler was noted. Per vaginal examination revealed cervical os 5 cm dilated, 40% effacement, breech presentation, absent membranes. With urgent report of complete hemogram and acid blood gas analysis, metabolic acidosis was noted which was corrected and patient was taken for emergency lower segment caesarean section. Intra-operative, 250 ml greenish pus flakes fluid was noted inside the abdominal cavity. Fluid was drained and sent for culture sensitivity with maximum aseptic precautions, uterus was opened, baby was delivered followed by uterus closure. Ruptured liver abscess 6×4×2 cm in 2nd and 3rd segment of liver was noted, abdominal wash with antibiotics and NS was given, drain was kept. Appropriate antibiotics were started and was discharged on day 14 after suture removal.

A Study of Radiological Appearances of Septic Pulmonary Embolism in Contrast Enhanced Computed Tomography Thorax

Introduction:Septic embolism, though dangerous and life threatening thenumber of cases reported are seldom. To diagnose septicembolism clinic-radiological correlation is must. Studyaimed to depict various radiological appearances of septicthromboembolism according to there frequency of occurenceand using clinical history to strengthen the suspicion of SPEin patients as SPE have grave prognosis if not detected early.Material and methods: Study was done in the GovernmentMedical College Surat including the subjects of clinicallysuspected septic pulmonary thromboembolism and studyingthe radiological pattern of their presentation during the year2018-2019.Results: In this study the most common radiologicalpresentation is feeding vessel sign seen in (90%) of patientsCT, the most common cause is liver abscess constituting (40%)of cases, the most common primary cause in the patients withcomplications and mortality is pneumonia and most commonsequelae is acute respiratory failure constituting (66%) ofmortality and most common chronic ailment association isdiabetes mellitus seen in (60%) of patients.Conclusion: Septic pulmonary embolism is life threateningbut diagnosis is difficult as there are no specific clinicalcomplaints and radiological features but for benefit of patientquick diagnosis and management must be started as it has highmortality rate. SPE should be considered in the differentialdiagnosis of patients presenting extrapulmonary infectivefocus, respiratory symptoms, and parenchymal pulmonarynodules on imaging studies of the chest.

Foreign body aspiration in children

Background: Foreign Body (FB) aspiration is a life-threatening problem in children. Here the demographic pattern, clinical presentation, type of Foreign Body (FB) and outcome of FB aspiration was examined.Methods: An observational case series study done in Institute of child health and research centre, Government Rajaji hospital, Madurai during November 2015 to June 2018. After a detailed history and clinical examination, children with definite evidence of FB in tracheobronchial tree were subjected to rigid bronchoscopy and with doubtful evidence were subject to FFBS. They were followed up for complications.Results: Of the 136 children, 86.03% (n=117) were under 3 years of age. A positive history of FB aspiration was present only in 51.4% (n=70). Unilateral hyperinflation was seen in 48.53% (n=66) but was normal in 13.97% (n=19). Flexible Fiber Optic Bronchoscopy (FFBS) diagnosed FBs in 61.02% (n=83) which included children with acute onset breathlessness and persistent radiological features. Peanut was the most common FB 64.71% (n=44). FBs were found in the right side in 50% (n=34) and in the left in 38.2% (n=26).' 36% (n=49) developed complications due to the FBs and 2.9% (n=4) due to procedure.Conclusions: FB aspiration is most common in children less than 3 years of age. Positive history of aspiration was seen in only 51.4% and chest X-ray was normal in 13.97%. FFBS diagnosed FB in 61.02%. Peanut was the most common FB. Persistent pneumonitis is the most common complication.

Etiology and clinical profile in chronic cor pulmonale

Background: Cor pulmonale is a synonym for pulmonary heart disease. The term 揷or pulmonale� if broken into its constituents 揷or� (heart) and 損ulmo� (lungs), means cardiac involvement due to pulmonary diseases. Chronic cor pulmonale is not a single disease entity but resulting secondary to many bronchopulmonary vascular diseases and also from thoracic cage abnormalities. Cor pulmonale accounts for 5-10% of all heart diseases, 20-30% of all admissions for heart failure and 9.2% in the cardiac autopsies.Methods: This was a hospital-based study carried among patients diagnosed with chronic cor pulmonale admitted to the medical wards of Karnataka institute of medical sciences, Hubli. during December 2011- November 2012 using simple random sampling method.Results: The following observations were made in 50 representative cases the age group of patients was between 24 to 85 years. Chronic cor pulmonale was commonly seen in middle and elderly age groups. Incidence below 35 years is very less. Almost every patient of chronic cor pulmonale presented with breathlessness and cough. All patients in the study had Tachypnoea, Diminished chest movements, Prominent use of accessory muscles of respiration, Cyanosis, Clubbing (in some patients), Crepitations and rhonchi on chest auscultation, Loud P2 and pansystolic murmur in Tricuspid area on cardiac auscultation.Conclusions: The peak incidence of chronic cor pulmonale was found to be in the middle and older age groups with high incidence during winter season. Smoking and dusty environment at the site of occupation were aggravating the primary lung disease. Breathlessness, cough and edema of the feet were the most common symptoms.

Effect Of 4 Week Expiratory Muscle Strengthening On Exercise Induced Breathlessness In Normal Adults-a Pilot Study

Background:During exercise, the expiratory phase plays an equally important role in improving endurance as it helps in reducing the exercise-induced breathlessness. Therefore this study aims at specifically strengthening the expiratory muscles to study the effect of expiratory muscle strengthening on exercise-induced breathlessness. Aims and objectives: To evaluate the effect of 4 weeks of expiratory muscle strengthening on exercise-induced breathlessness in normal individuals. Methodology:Study was carried out on a total of 13 subjects ranging in the age group of 20-35yrs, where pre-intervention the Maximum Expiratory Pressure (MEP) and 1.5mile walk distance was calculated after which the subjects underwent a 4 week intervention protocol using Expiratory Muscle Strength Trainer 150 ( EMST-150) where the subjects performed 25 training breaths in one session where there were a total of 5 sessions in a day, 5days/week for a total of 4 weeks. Post the intervention the MEP and 1.5mile walk values were recalculated and compared to check for the difference. Result:Data was analyzed in terms of the mean difference. Statistically significant change was seen in the MEP and 1.5 mile walk test values post-intervention, i.e at the end of 4 weeks, where the values obtained were, MEP : pre –77.537 ±13.67 and post ­­–88.063 ±18.39 with a p-value of 0.0019 , 1.5 mile walk(vo2max.) : pre –35.810 ±14.56 and post –39.810 ±11.8 with a p-value of 0.0038 and RPE: pre –3.80 ±0.5 and post –1.7 ±0.5 with a p-value of 0.0057, thereby proving a statically significant improvement in the outcome measures. Conclusion: The study concludes that Expiratory muscle strengthening improves the maximum expiratory strength thereby reducing the exercise-induced breathlessness leading to an improvement in the endurance level.

Respiratory symptoms among auto rickshaw drivers of Mangaluru

Background: Auto rickshaw drivers spend their maximum time in polluted, dangerous, and very noisy environment. They are exposed to harmful pollutant gas such as carbon monoxide and sulfur dioxide which can contribute to the development of chronic obstructive pulmonary disease, asthma, breathlessness, and chest pain. Objectives: The present study was aimed to estimate respiratory symptoms and peak expiratory flow rate (PEFR) among auto rickshaw drivers. Materials and Methods: Cross-sectional descriptive study was conducted among auto rickshaw drivers working in Mangaluru. Information regarding sociodemographic profile, dietary habits, addictions, and working hours were collected, and respiratory examination along with PEFR estimation was done. Results: The maximum study participants were in the age group of 41–50 years, and 56.4% participants were working for >10 h per day. The main respiratory symptoms were breathlessness (28.7%) followed by cough (19.7%). Among 188 study participants, 61 (32.4%) had low PEFR. Conclusion: The respiratory symptoms are quite high among auto rickshaw drivers, and there is a need to increase awareness among them for the prevention of occupational disease.

Report of One Case, Successfully Managed with Fentanyl for the Relief of Breathlessness in a Patient with Lung Cancer / 日本プライマリ・ケア連合学会誌

Morphine is the only opioid that has been found effective for the relief of dyspnea in cancer patients. However, efficacy has not been fully demonstrated for other opioids such as fentanyl. Here, we report a case of lung cancer in which the use of fentanyl was effective for the relief of dyspnea. The patient was an 88-year-old man who had cT4N2M0, cStage IIIB lung cancer with right bronchial involvement and mediastinal lymph node metastases. Although the patient complained of dyspnea, he was not given morphine due to underlying renal dysfunction. He instead received oxygen therapy, and treatment with oral steroids and oxycodone. As oral administration became more difficult with subsequent lung cancer progression, the patient underwent opioid switching from oxycodone to subcutaneous injections of fentanyl. Dyspnea was not exacerbated following the switching, and was thereafter effectively managed by increasing the fentanyl dose and using rescue medication. Fentanyl is suggested to be a possible therapeutic option for dyspnea in cases where the use of morphine is difficult.

Guidelines for Bystander First Aid 2016

Cardiac life support is a form of first aid for cardiac emergencies. However, research and evidence in this field is lacking compared with other forms of first aid. Having identified the common emergencies that are encountered in the hospital, based on the available evidence, we have put together what could be an evidence-based approach to the first aid management of some of these common emergencies, viz. breathlessness, chest pain, allergies, stroke, heat injury, poisoning, unconsciousness, seizures, and trauma situations such as bleeding, wounds, contusions, head injury, burns and fractures. Educating the public is the key to developing a first responder bystander. These guidelines could become the basis for training of the public.

To assess the pulmonary impairment in treated pulmonary tuberculosis patients using spirometry

Background: Tuberculosis is one of the leading causes of death due to infectious Disease worldwide, with an estimated 8.9 million new cases and 1.6 million Deaths worldwide. Aim: To study the type and degree of pulmonary impairment in treated pulmonary Tuberculosis patients using spirometry. To co -relate present symptoms and radiological findings and to assess the degree of impairment. For identification of impairment (obstructive, restrictive or mixed) that contribute to long term disability and decreased quality of life. Materials and methods: Retrospective observational study was done in Meenakshi Medical College Hospital. A total of 75 treated pulmonary tuberculosis patients were taken for study with clinical data, chest x-ray pattern, smoking and biomass fuel exposure history were recorded. Their pulmonary function was assessed using spirometry. Results: All patients were symptomatic and most common symptom was breathlessness. Chest radiograph showing 1 or 2 zones involved patients were 40 (53.3%) and more than 3 zones involved were 35 (46.7%).Most of the patients 51 (68%) showed a Restrictive pattern in spirometry, 10 (13.3%) showed an obstructive pattern and 14 (18.7%) showed a mixed pattern. Smoking and Biomass fuel exposure did not show a significant co-relation with spirometry pattern but initial sputum positive patients and defaulter patients showed a significant co-relation with spirometry pattern. Conclusion: The most common pulmonary impairment pattern in treated pulmonary tuberculosis patients was Restrictive pattern. Hence pulmonary tuberculosis need follow up even after treatment for early detection and treatment for their pulmonary disability

BREATHLESSNESS

Breathlessness, also known as dyspnoea, is a common presenting complaint in the outpatient family physician clinic. It is most commonly caused by respiratory and cardiac disorders, but there are lots of other important aetiologies that need to be considered. The initial goal of assessment is to determine the severity of the dyspnoea, considering the need for oxygen therapy and intubation. Unstable patients usually present with abnormal vital signs, hypoxia, diaphoresis, and/or altered mental states, and require urgent management. Ongoing care depends on the differential diagnosis established by an adequate history and physical examination, and investigations, if available, can aid definitive diagnosis. The family physicians must be equipped to initiate appropriate therapy, conduct continuous monitoring and stabilise an acutely dyspnoeic patient before determining the final disposition of the patient.

Pitfalls and Red Flags in Common Clinical Syndromes

Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.

Pitfalls and Red Flags in Common Clinical Syndromes

Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.

Gender and perception of dyspnea: The role of the variation in the forced expiratory volume in one second / Género y percepción de disnea: el rol de la variación del volumen espiratorio forzado en un segundo

During bronchoconstriction women perceive more breathlessness than men. The aims of study were 1) to evaluate if quality of dyspnea in bronchoconstriction was different in women and men 2) to assess if gender difference in the perception of dyspnea could be related to the level of bronchoconstriction. 457 subjects (257 women) inhaled methacholine to a 20% decrease in FEV1, or 32 mg/ml. Dyspnea was evaluated using the modified Borg scale and a list of expressions of dyspnea. Borg scores were recorded immediately before the challenge test baseline and at the maximum FEV1 decrease. The prevalence of descriptors of dyspnea reported by women and men was similar. Dyspnea was related to the level of FEV1 (ΔFEV1: OR 1.05, 95%CI 1.01-1.09, p 0.0095), females (OR 2.90, 95%CI 1.33-6.33, p 0.0072), younger subjects (OR 0.93, 95%CI 0.89- 0.97, p 0.0013) and body mass index (BMI) (OR 1.11, 95%CI 1.01-1.23, p 0.023). As the FEV1 fell less than 20% from baseline, only the ΔFEV1 was significantly associated with dyspnea (ΔFEV1:OR 1.15, 95%CI 1.07- 1.24, p 0.0002). Instead, if the FEV1 fell higher ≥ 20%, the presence of dyspnea was related to the degree of bronchoconstriction (ΔFEV1: OR 1.04, 95%CI 1.01-1.09, p 0.0187), females (OR 3.02, 95%CI 1.36-6.72, p 0.0067), younger subjects (OR 0.92, 95%CI 0.88-0.96, p 0.0007) and BMI (OR 1.12, 95%CI 1.01-1.23, p 0.023). The quality of dyspnea during the bronchoconstriction was similar in women and men; women showed a higher perception of dyspnea than men only when the FEV1 fell more than 20% from baseline.

Durante la broncoconstricción las mujeres perciben más disnea que los hombres. Los objetivos del estudio fueron evaluar: 1) si la calidad de la disnea durante la broncoconstricción fue diferente en mujeres y hombres, 2) si la diferencia entre sexos en la percepción de disnea podría relacionarse al nivel de broncoconstricción. 457 sujetos (257 mujeres) inhalaron metacolina hasta un descenso del FEV1 ≥ 20% o 32 mg/ml. La disnea fue evaluada mediante escala de Borg y una lista de expresiones de disnea. El Borg fue registrado en forma basal y con el máximo descenso del FEV1. La frecuencia de descriptores de disnea informados por mujeres y hombres fue similar. La disnea estuvo relacionada al grado de broncoconstricción (ΔFEV1: OR 1.05, 95%CI 1.01-1.09, p 0.0095), sexo femenino (OR 2.90, 95%CI 1.33-6.33, p 0.0072), edad (OR 0.93, 95%CI 0.89-0.97, p0.0013) e índice de masa corporal (IMC) (OR 1.11, 95%CI 1.01-1.23, p 0.023). Cuando el FEV1 cayó menos del 20%, solo el ΔFEV1 se asoció con disnea (ΔFEV1: OR 1.15, 95%CI 1.07-1.24, p 0.0002). En tanto que si el FEV1 cayó ≥ del 20%, la disnea estuvo relacionada al grado de broncoconstricción (ΔFEV1: OR 1.04, 95%CI 1.01-1.09, p 0.0187), sexo femenino (OR 3.02, 95%CI 1.36-6.72, p 0.0067), edad (OR 0.92, 95%CI 0.88-0.96, p 0.0007) e IMC (OR 1.12, 95%CI 1.01-1.23, p 0.023). La calidad de la disnea durante la broncoconstricción fue similar en hombres y mujeres; las mujeres tuvieron mayor percepción de disnea que los hombres solo cuando el FEV1 descendió más del 20%.

The role of general practitioners in home oxygen therapy

Recommendation of oxygen therapy must include clear indication and benefits of its use, appropriate prescription, vigilant monitoring and appropriate methods of delivery. Home oxygen therapy is expensive, inconvenient and cumbersome; it should be recommended only if benefits outweigh the disadvantages and adverse effects of oxygen. GPs play an important supportive and supervisory role in the use of long-term oxygen therapy (LTOT) to improve mortality of patients with chronic hypoxaemia. Prescription of short burst oxygen therapy (SBOT) for palliation of breathlessness is without clear evidence of its efficacy. GPs can prescribe SBOT when other secondary causes of breathlessness are excluded or treated, when breathlessness is not relieved by other treatments and if an improvement can be documented in patients.