Expert Opinion on the Management of Acute and Chronic Cough: An Indian Perspective in Primary Care Setting.

Cough is the body's reflex when the throat or airway is irritated by a foreign body, such as irritants, microbes, and fluids. Cough caused due to a disorder or infection can last for a few days to a couple of weeks and is usually self-limiting and self-resolving. However, in certain cases, cough can persist for months, disrupting everyday activities, affecting the patient's mental health, and causing pain and fatigue. There are a number of different therapeutic strategies to manage acute and chronic cough, depending on the cause. Dry cough can be treated using opioids, nonopioids, antitussives, and antihistamines. Expectorants and mucolytics are widely used in the management of productive cough. The underlying cause of cough should be appropriately managed with specific therapy. The choice of treatment regimen is dependent on the patient's medical history, symptoms, and preexisting conditions. Based on the literature review and clinical practice, a comprehensive approach to the management of cough as a symptom has been proposed.

Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Household air pollution in India and respiratory diseases: current status and future directions.

PURPOSE OF REVIEW: Combustion of solid cooking fuels employed by more than 3 billion people globally, contributes to approximately one third of ambient air pollution. In the recent past, the issue has drawn global attention because of its threat to the health of rural communities, particularly women and children. This review is focused on the evidence from India on effects of household air pollution (HAP) on respiratory health and interventions to replace the solid fuels. RECENT FINDINGS: HAP exposure is a major risk factor for increased respiratory symptoms, respiratory infections, and chronic obstructive pulmonary disease. In most studies, the odds ratio for the risk of development of respiratory disorders is more than one in HAP exposed individuals. HAP is also associated with increased risk of tuberculosis, asthma, mortality from cardio-respiratory illnesses, and nonrespiratory problems such as adverse pregnancy outcomes, prematurity, and low birth weight. SUMMARY: Household air pollution is a common but preventable risk factor for respiratory diseases. Replacement of solid cooking fuels with clean fuels such as LPG gas as exemplified by the 'Ujjwala' program of India is likely to be most effective intervention to reduce the HAP related disease burden.

Guidelines for Diagnosis and Management of Bronchial Asthma: Joint Recommendations of National College of Chest Physicians (India) and Indian Chest Society.

Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

The effect of biomass fuel exposure on the prevalence of asthma in adults in India - review of current evidence.

INTRODUCTION: The combustion of biomass fuels is a major source of respiratory disease among individuals in the developing world. Over two million people world-wide rely on biomass fuels to supply their household energy needs with an estimated 1.6 million deaths annually being attributable to biomass smoke exposure. As a developing country, India relies heavily on the use of solid fuels as a source of energy. These materials supply 75% of the country's domestic energy need and are attributed as the cause of over 600 000 deaths annually. Diseases such as chronic bronchitis and acute lower respiratory tract infections are strongly correlated to biomass smoke exposure. While not as strongly correlated, accumulating evidence suggests that asthma prevalence may be related to solid fuel smoke. METHODS: This review examines the current literature linking biomass smoke exposure to the reporting of asthma symptoms. A PubMed search was performed using key terms biomass, asthma, India and respiratory disease. Preference was given to recent articles that surveyed the adult population within India. RESULTS: The reviewed articles showed an increased odds ratio for reporting a diagnosis of asthma or symptoms consistent with asthma following biomass smoke exposure. While the literature supports a strong association between household air pollution and the development of chronic bronchitis and acute lower respiratory tract infections in India, this review establishes a more firm relationship between reported asthma symptoms and biomass smoke exposure. CONCLUSION: The exposure to biomass fuel smoke results in respiratory diseases in developing countries. Among these diseases, asthma appears to be a preventable pulmonary pathology that is associated with household air pollution. Measures to reduce exposure may decrease the burden of disease which could help advance social and economic progress in these nations. Further research and out-reach efforts are needed to reduce the total burden of lung diseases, including asthma, across the developing world. This reduction could save millions of dollars annually and lower morbidity and mortality in the affected populations.

Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).

INTRODUCTION: Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing. METHODS: Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake. OUTCOME: The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms. CONCLUSION: These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures.

Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.

Sarcoidosis and tuberculosis: the same disease with different manifestations or similar manifestations of different disorders.

PURPOSE OF REVIEW: Ever since sarcoidosis was first described, its relationship with tuberculosis has been debated. Whereas some consider sarcoidosis and tuberculosis as two extremes of the same disease process, other researchers have negated the role of mycobacteria in causation of sarcoidosis. Whether or not linked causally, there are obvious clinical similarities that make differential diagnosis of the two conditions very challenging, particularly in countries with high burden of tuberculosis. Herein we analyze the relationship between sarcoidosis and tuberculosis and its implications in clinical practice. RECENT FINDINGS: Initial studies had focused on finding an epidemiological link between the two conditions or demonstration of mycobacteria in sarcoid lesions on histology. Results from these studies were at best suggestive. Recent molecular and immunological studies suggest mycobacterial antigens are the inciting agents in a proportion of sarcoidosis patients. Evidence is stronger from countries with high burden of tuberculosis. Tuberculosis can manifest as a complication of treatment in sarcoidosis and the two conditions can rarely co-exist. SUMMARY: The balance of evidence favors mycobacteria or their products as a trigger for inciting immune responses leading to sarcoidosis in a proportion of patients, which is likely to be higher in countries with high tuberculosis burden. This evidence also highlights the limitations of molecular or serological studies to discriminate between the two conditions.

A survey of noninvasive ventilation practices in a respiratory ICU of North India.

BACKGROUND: There is paucity of data from India on the use of noninvasive ventilation (NIV) in acute respiratory failure (ARF). In this observational study, we report the indications and outcomes of patients requiring NIV in the respiratory ICU of a tertiary care hospital. METHODS: All patients with ARF requiring NIV were included in the study. NIV was delivered through critical care ventilators, using oronasal mask. The disease severity and new-onset organ dysfunction/failure were calculated using the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, respectively. A multivariate logistic regression model was used to analyze the factors predicting NIV failure. RESULTS: There were 92 subjects (48 men, 44 women, mean ± SD age 48 ± 17.5 y) who received 101 NIV applications (42 and 59 applications for episodes of hypoxemic and hypercapnic ARF, respectively) during the study period. The most common causes of hypoxemic and hypercapnic respiratory failure were acute lung injury/ARDS (29%) and COPD (29%), respectively. There was significant improvement in heart rate and respiratory rate after 1, 2, and 4 hours, compared to the baseline, in both the groups. Of the NIV applications, 53.5% required endotracheal intubation, with the number being significantly higher in hypoxemic (67%), compared to hypercapnic (44%), ARF (P = .03). The P(aO(2))/F(IO(2)) measured after 1 hour of NIV application had significant impact on outcome in patients with hypoxemic but not hypercapnic ARF. A P(aO(2))/F(IO(2)) of ≤ 146 mm Hg at one hour had a better specificity (85.7% vs 71.4%), versus a P(aO(2))/F(IO(2)) of ≤ 175 mm Hg in predicting NIV failure in patients with hypoxemic ARF. On multivariate logistic regression analysis, baseline APACHE II score, ΔSOFA score, hypoxemic respiratory failure, and change in P(aO(2))/F(IO(2)) at 1 hour from baseline were associated with NIV failure. CONCLUSIONS: NIV was found to be a useful modality in management of patients with hypercapnic versus hypoxemic respiratory failure. The severity of illness at admission, new-onset organ dysfunction, hypoxemic ARF, and delay in improvement in P(aO(2))/F(IO(2)) at 1 hour from baseline are independent predictors of NIV failure.

Is pulmonary tuberculosis a true risk-factor for chronic obstructive pulmonary disease?

This viewpoint discusses the possible relationship of tuberculosis with chronic obstructive pulmonary disease. Pulmonary tuberculosis as a risk factor and/or complication of COPD is reported in several reports from African and Asian countries. History of TB seems to have an important role in the natural history of COPD. It is difficult to conclude whether this is a true causal relationship or merely an incidental observation due to the concurrent presence of the two commonly prevalent diseases and their risk factors. Many of these disease and treatment-related factors can promote and/or aggravate disease condition.

A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis.

BACKGROUND AND OBJECTIVE: Talc is an effective and widely used agent for chemical pleurodesis. However, limited availability and high cost hamper the routine use of talc in resource poor countries. In this study, we compared the efficacy and safety of iodopovidone with that of cosmetic talc, for chemical pleurodesis. METHODS: Patients with recurrent pleural effusions and/or spontaneous pneumothorax were prospectively randomized to undergo pleurodesis with cosmetic talc (5g) or iodopovidone (20mL of a 10% solution) by tube thoracostomy. The cosmetic talc was pretested for impurities (asbestos-free) and particle size (20-60µm), using energy dispersive analysis by X-ray and scanning electron microscopy. The success rate (complete or partial), time to pleurodesis and safety of these two agents was compared. RESULTS: Pleurodesis was performed in 73 patients (39 with iodopovidone, 34 with cosmetic talc; 56 men, 17 women; mean age 51.7 years; 38 pleural effusions, 35 pneumothoraces). A complete response was obtained in all patients with pneumothorax in both the iodopovidone and talc groups. Among patients with pleural effusions, a complete response was observed in 16/19 and 15/19 patients in the iodopovidone and talc groups, respectively. A partial response was observed in two additional patients from each group. The time to pleurodesis was similar in the two groups. Minor side-effects (fever, chest pain) were observed with similar frequencies in the two groups. None of the patients experienced hypotension or ARDS. CONCLUSIONS: Iodopovidone and cosmetic talc are equally efficacious and safe agents for chemical pleurodesis.

Comparison of the lower confidence limit to the fixed-percentage method for assessing airway obstruction in routine clinical practice.

BACKGROUND: Although the statistically derived lower limit of normal (LLN) for the ratio of FEV(1) to FVC is considered superior to a fixed cutoff value (such as 0.70) for diagnosing airway obstruction, the fixed-cutoff method continues to be used and advocated. OBJECTIVE: To evaluate the misclassification of spirometrically determined airway obstruction arising from the use of the fixed-percent method, in comparison to the LLN method for FEV(1)/FVC. METHODS: We reviewed 27,307 spirometry records from adult men, and diagnosed airway obstruction based on the LLN (predicted value minus 1.645 times the standard error of estimate from a north Indian reference equation for FEV(1)/FVC) and based on a fixed cutoff of 0.70. We computed agreement and discordance between the two methods, and determined the sensitivity, specificity, and predictive values of the fixed-percent method in identifying true obstruction. RESULTS: The results were discordant in 1,622 subjects (6%). Overall agreement between the two methods was good (kappa estimate 0.869), but worsened considerably with advancing age. 1,290 subjects (5%) who were deemed normal with the LLN method were diagnosed as having airway obstruction with the fixed-percentage method. Overall the sensitivity, specificity, and positive predictive value of the fixed-percentage method were 0.963, 0.929, and 0.871, respectively. Specificity and positive predictive value decreased sharply with advancing age. CONCLUSIONS: The negative age-dependence of FEV(1)/FVC results in over-diagnosis of airway obstruction in middle-aged and elderly men, and under-diagnosis in young men, with the fixed-percentage method. Airway obstruction should be assessed with the LLN of FEV(1)/FVC, with the LLN derived from appropriate reference equations.

Aspergillus hypersensitivity in patients with chronic obstructive pulmonary disease: COPD as a risk factor for ABPA?

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus which primarily complicates the course of asthma and cystic fibrosis. There is a theoretical possibility that patients with chronic obstructive pulmonary disease (COPD) can also develop Aspergillus hypersensitivity (AH) and/or ABPA. The aim of this prospective case-control study conducted in the Chest Clinic was to evaluate the prevalence of AH/ABPA in patients with COPD. Two hundred subjects with COPD (17, 62, 74, 47; GOLD guidelines stages I–IV respectively) and 100 healthy volunteers were screened with an Aspergillus skin test. Patients were said to have AH if they demonstrated immediate cutaneous hyperreactivity to A. fumigatus antigen and those with positive responses were further investigated for ABPA. Of this patient population there were 179 (89.5%) males and 21 (10.5%) females with a mean age of 57.1 in the COPD arm and 88 males and 12 females with a mean age of 52.3 in the control arm. AH was found in 17 (8.5%) patients with COPD as compared to none in the control group. Two (1.0%) COPD patients fulfilled the serologic criteria for the diagnosis of ABPA. On univariate analysis, age of the patient, duration of COPD, smoking index and the COPD severity did not predict the occurrence of AH. On the basis of this study we concluded that AH/ABPA can occur in patients with COPD, and it is probable that COPD could be a predisposing factor for AH/ABPA. The clinical significance of AH and ABPA in COPD remains unclear.

Validation of a Hindi translation of Mini Asthma Quality of Life Questionnaire in north Indian patients with bronchial asthma.

BACKGROUND AND OBJECTIVE: There is little information on validated health-related quality of life (HRQoL) instruments for use in Indian patients with bronchial asthma. We attempted to validate the Hindi translation of Juniper's mini asthma quality of life questionnaire (MiniAQLQ) in north Indian patients with bronchial asthma. METHODS: Hindi translation of MiniAQLQ, and abbreviated World Health Organization quality of life questionnaire (WHOQOL-Bref), were administered to 30 patients with bronchial asthma twice at a six-week interval. Clinical and physiological data were also recorded. Psychometric properties (acceptability, validity, reliability and responsiveness) of MiniAQLQ were assessed after calculating four domain (physical, psychological, social relationships and environment), and a total score. RESULTS: Most questionnaires were returned without missing responses. MiniAQLQ had good convergent and discriminant validity, but moderate content and construct validity. All components (except emotional function domain) met standards for internal consistency (Cronbach's alpha coefficient >0.70), but intra-class correlation coefficients were variable. Change in MiniAQLQ scores between two assessments correlated poorly with corresponding changes in lung function. The effect sizes ranged from 0.02 to 0.34 in 11 patients whose forced expiratory volume in the first second (FEV1) changed by >200mL and >12% from baseline, and were considered small. CONCLUSION: The Hindi translation of MiniAQLQ is a moderately good discriminative and a relatively poor evaluative instrument to assess health related quality of life (HRQoL) in north Indian patients with bronchial asthma.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP).

BACKGROUND: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. METHODS: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. RESULTS: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. CONCLUSION: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

An assessment of nutritional support to critically ill patients and its correlation with outcomes in a respiratory intensive care unit.

BACKGROUND: Nutritional support is frequently neglected in a busy intensive care unit (ICU) with overworked staff. There is a paucity of investigations on ICU nutrition from India. OBJECTIVES: To assess the adequacy of nutritional support administered to patients requiring mechanical ventilation in the respiratory ICU of a tertiary-care institute, and its correlation with outcomes. METHODS: This was a prospective cohort study of patients >or= 15 years old who underwent mechanical ventilation for at least 24 hours and had a respiratory ICU stay of at least 48 hours. Enteral nutritional support was initiated as early as possible after respiratory ICU admission. The daily calorie and protein prescription was 30 kcal/kg and 1.2 g/kg ideal body weight, respectively, with appropriate adjustments for critical illness(es) and comorbidities. Anthropometric and laboratory parameters were assessed serially. Risk factors for hospital mortality were evaluated using multivariable logistic regression analysis. RESULTS: During the study period, 258 patients were admitted to the respiratory ICU, of whom 93, who fulfilled all the inclusion criteria, composed the study population. Calorie prescription increased from a median and interquartile range (IQR) of 88.9% (80.4-99.0%) of the recommended value on day 1 to 114.4% (99.9-122.5%) on day 21. Protein prescription improved from 80.1% (67.1-90.6%) of the recommended value on day 1 to 98.4% (76.1-120.8%) on day 28. Calorie delivery increased from 55.1% (35.4-81.3%) of the recommended value on day 1 to 92.0% (35.7-124.6%) on day 28. Protein delivery improved from 46.7% (31.6-72.1%) of the recommended value on day 1 to 75.3% (54.3-85.5%) on day 28. Risk factors for hospital mortality identified were admission Sequential Organ-Failure Assessment score (odds ratio 1.30, 95% confidence interval 1.03-1.63) and mean daily calorie delivery of