A young male with non-resolving consolidation and hepatosplenomegaly.

ABSTRACT: Non-resolving consolidation refers to the persistence of radiographic abnormalities beyond the anticipated timeframe. Conditions such as infection, malignancy, inflammatory disorders, and connective tissue diseases can all manifest as non-resolving consolidation. We share a clinicopathological case study involving a 30-year-old male who exhibits non-resolving consolidation accompanied by hepatosplenomegaly.

Comparison of lung aeration loss in open abdominal oncologic surgeries after ventilation with electrical impedance tomography-guided PEEP versus conventional PEEP: a pilot feasibility study.

BACKGROUND: Existing literature lacks high-quality evidence regarding the ideal intraoperative positive end-expiratory pressure (PEEP) to minimize postoperative pulmonary complications (PPCs). We hypothesized that applying individualized PEEP derived from electrical impedance tomography would reduce the severity of postoperative lung aeration loss, deterioration in oxygenation, and PPC incidence. METHODS: A pilot feasibility study was conducted on 36 patients who underwent open abdominal oncologic surgery. The patients were randomized to receive individualized PEEP or conventional PEEP at 4 cmH2O. The primary outcome was the impact of individualized PEEP on changes in the modified lung ultrasound score (MLUS) derived from preoperative and postoperative lung ultrasonography. A higher MLUS indicated greater lung aeration loss. The secondary outcomes were the PaO2/FiO2 ratio and PPC incidence. RESULTS: A significant increase in the postoperative MLUS (12.0 ± 3.6 vs 7.9 ± 2.1, P < 0.001) and a significant difference between the postoperative and preoperative MLUS values (7.0 ± 3.3 vs 3.0 ± 1.6, P < 0.001) were found in the conventional PEEP group, indicating increased lung aeration loss. In the conventional PEEP group, the intraoperative PaO2/FiO2 ratios were significantly lower but not the postoperative ratios. The PPC incidence was not significantly different between the groups. Post-hoc analysis showed the increase in lung aeration loss and deterioration of intraoperative oxygenation correlated with the deviation from the individualized PEEP. CONCLUSIONS: Individualized PEEP appears to protect against lung aeration loss and intraoperative oxygenation deterioration. The advantage was greater in patients whose individualized PEEP deviated more from the conventional PEEP.

Swiss Cheese Trachea: An Unwarranted, Unique Form of Post-intubation Tracheal Stenosis.

How to cite this article: Bajad P, Pahuja S, Agarwal S, Khanna A. Swiss Cheese Trachea: An Unwarranted, Unique Form of Post-intubation Tracheal Stenosis. Indian J Crit Care Med 2024;28(1):84-85.

A rare primary tracheal tumor.

A 20-year-old male without any prior comorbidities presented with 6-month history of hemoptysis as the sole symptom. Clinico-radiological profile and bronchoscopy were suggestive of a tracheal mass. This clinico-pathologic conference discusses the differential diagnoses of primary tumors of the trachea and their management options.

Pulmonary-Renal Syndrome: A Real-World Experience From a Tertiary Care Pulmonary Center in North India.

BACKGROUND: Pulmonary renal syndrome (PRS) is a simultaneous occurrence of diffuse alveolar hemorrhage (DAH) and glomerulonephritis (GN). The diagnosis of PRS not only requires a high index of clinical suspicion and prompt management, but it is often fatal due to rapidly progressive clinical deterioration despite aggressive treatment. The authors, therefore, share the real-world experience of PRS presenting to tertiary care pulmonary center in north India. AIMS: The objectives of the study were to identify etiology, clinical manifestations, treatment modalities and outcomes of patients presenting with PRS. MATERIALS & METHODS: This was a retrospective observational study undertaken at Metro Centre for Respiratory Diseases of patients diagnosed with PRS during the last two years between 2019 and 2021. The patients diagnosed with PRS based on clinical manifestations, serology and biopsies were included in the study. All cases of non-immunological causes of PRS were excluded from the study. Chi-square and Mann-Whitney U tests were done to look for associations obtained between survivors and non-survivors. Cox regression analysis was done to estimate the hazard ratios of clinical variables on survival in PRS patients. RESULTS: A total of 12 patients of PRS were included in the study and diagnosis was made based on clinical manifestations, serology as well as biopsies. The mean age of presentation was 45.4 (± 17.8) years and 66.7% of the patients were females. The most common etiology was anti-nuclear cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) seen in 83.3% of the cases. The most common symptoms were coughing and fever (80%) followed by dyspnea and hemoptysis (70%) with the mean duration of symptoms being 17.1 (±8.9) days. The mortality of PRS patients in our study was 41.6% and these patients had a higher acute physiology and chronic health evaluation (APACHE) score (median-26) compared to those patients who survived (median - 15.8). CONCLUSION: The occurrence of PRS, although rare, presents with rapid clinical deterioration leading to a high mortality rate. AAV was the most common cause of PRS as observed in our study. Early recognition and prompt aggressive management strategies with immunosuppressant therapies are essential for better outcomes for the patients.

Effects of Neurally Adjusted Ventilation Assist (NAVA) and conventional modes of mechanical ventilation on diaphragm functions: A randomized controlled trial.

BACKGROUND: Better patient-ventilator interactions, during neurally adjusted ventilator assist (NAVA), are expected to result in lower rate of diaphragm dysfunction. OBJECTIVE: This study was planned to compare the rate of diaphragm dysfunction between the conventional modes of mechanical ventilation and NAVA. METHODS: Patients who were initiated on mechanical ventilation for acute respiratory failure were randomized to continue either conventional mode of mechanical ventilation or switched to NAVA. The rates of diaphragm dysfunction were compared between two groups. RESULTS: This study included 46 participants (male 30/46) with a mean age of 58 years. Mean APACHE II and SOFA scores were 15 and 3, respectively. The mean (SD) diaphragm thickness fraction in the conventional mechanical ventilation and NAVA group were 37.12% (18.48) and 39.27% (27.65), respectively. The diaphragm dysfunction was observed in 5 (22.7%) and 8 (34.7%) patients in NAVA and conventional arm, respectively. There was no statistically significant difference between the two groups (p-value = 0.37). Diaphragm excursion was better in the NAVA group as compared with the conventional mechanical ventilation group. Diaphragm thickness and thickness fraction were comparable between two groups. CONCLUSION: Switching from the conventional mode of mechanical ventilation to NAVA leads to statistically non-significant reduction in the occurrence of diaphragm dysfunction. Adequately powered studies are required to assess the exact role of NAVA on diaphragm functions.

Clinical features, demography, and predictors of outcomes of SARS-CoV-2 infection at a tertiary care hospital in India: A cohort study.

BACKGROUND: The "second wave" of the COVID-19 pandemic hit India from early April 2021 to June 2021. We describe the clinical features, treatment trends, and baseline laboratory parameters of a cohort of patients with SARS-CoV-2 infection and their association with the outcome. METHODS: This was a retrospective cohort study. Multivariate logistic regression models were fitted to identify clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay, and death. RESULTS: A total of 2080 patients were included. The case fatality rate was 19.5%. Among the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged >45 years had higher odds of death as compared to the 18-44 years age group. Vaccination reduced the odds of death by 40% (odds ratio [OR] [95% confidence interval [CI]]: 0.6 [0.4-0.9], P = 0.032). Patients with hyper inflammation at baseline as suggested by leukocytosis (OR [95% CI]: 2.1 [1.5-3.1], P < 0.001), raised d-dimer >500 mg/dL (OR [95% CI]: 3.2 [2.2-4.7], P < 0.001), and raised C-reactive peptide >0.5 mg/L (OR [95% CI]: 3.7 [2.2-13], P = 0.037) had higher odds of death. Patients who were admitted in the 2nd week had lower odds and those admitted in the 3rd week had higher odds of death. CONCLUSION: This study shows that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Improving vaccination rates and early admission of patients with moderate and severe COVID-19 can improve the outcomes.

The Effectiveness of SARS-CoV-2 Vaccination in Preventing Severe Illness and Death - Real-world Data from a Cohort of Patients Hospitalized with COVID-19.

Background: While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited for SARS-CoV-2 vaccine, studies on breakthrough infections help understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness. This study aims to compare the differences in the hospitalization outcomes SARS-CoV-2 infection of fully vaccinated individuals with with those of unvaccinated and partially vaccinated individuals. Materials and Methods: Single institution observational cohort study. This study compared the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection. Descriptive statistics and propensity-score weighted multivariate logistic regression analysis adjusting for clinical and laboratory parameters were used to compare the differences and to identify factors associated with outcomes. Results: Completing the course of vaccination protected individuals from developing severe COVID-19 as evidenced by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support, and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India. Conclusions: Efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.

A retrospective observational study on pheno-endotypes of severe asthma among adults attending asthma clinic in a tertiary care centre in India.

Background and Objective: Severe asthma phenotyping based on invasive and non-invasive bio-markers assists in a better understanding of heterogeneity of clinical presentations and thereby using targeted therapies. Therefore, the current study was conducted to evaluate phenotypes based on non-invasive bio-markers of severe asthma patients attending a tertiary care hospital in North India. Methods: This was a retrospective, observational study conducted on the patients who visited the respiratory department of a tertiary care hospital in North India. Patients aged 18 years and above diagnosed with severe asthma were classified into distinct phenotypes, namely, atopic asthma, eosinophilic asthma, and Type 2 low asthma. Patients with their clinical and functional parameters were classified based on the levels of bio-chemical and hematological results [such as total/specific IgE, blood absolute eosinophil count (AEC)], skin prick tests, history of allergy, and the presence of allergic symptoms. Results: Out of total 100 severe asthmatics, the majority of the patients had an eosinophilic asthma (49%) phenotype, followed by atopic (allergic) asthma (36%) and Type 2 low asthma (15%) phenotypes. However, it was found that 29% of these patients had overlap of both atopy and eosinophilia. The atopic phenotype showed allergic symptoms, positive skin prick tests, and elevated IgE levels. The eosinophilic phenotype had high AEC (≥300 cells/uL) and low IgE (< 30 IU/ml) levels. The Type 2 low phenotype showed low AEC and IgE levels along with the absence of allergic symptoms. However, among these 100 patients, overlapping traits of both atopy and eosinophilia were labelled as overlap phenotypes. 50% of type 2 low severe asthma cases had eosinophils >150 cells/cmm and were eligible for mepolizumab. Conclusions: Identification of severe asthma pheno-endotypes based on simple non-invasive bio-markers is feasible in Indian settings, and it is of utmost importance for future treatment planning in these patients with available biologicals. Overlap of eosinophilic and atopic endotypes in one-third cases would challenge physicians to choose upfront appropriate biologicals in our country. Type 2 low asthma was least common with only <10% cases of severe asthma being ineligible for any biological.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice.

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Weather Parameters and COVID-19: A Correlational Analysis.

OBJECTIVES: To assess the effect of ambient temperature, humidity and wind speed on disease occurrence in Delhi, India. DATA AND METHODS: Data regarding daily corona cases, temperature, humidity, wind speed, doubling time and basic reproduction number (R0) was retrieved from online sources. Pearson's coefficient was used to assess the correlation between daily as well as weekly corona cases and various environmental factors. RESULTS: During the study period of 97 days, there was a steady rise in number of corona cases with median (interquartile range) cases per day being 224 (58 to 635). The doubling time demonstrated a strong positive correlation with temperature while R0 had strong negative correlation with temperature (correlation coefficients 0.814 and -0.78, respectively). No significant correlation with humidity or wind speed was observed. CONCLUSION: Increasing temperature decreases COVID-19 infectivity; however, actual role of environmental factors in expansion of pandemic needs further evaluation globally.

Clinico-demographic profile & hospital outcomes of COVID-19 patients admitted at a tertiary care centre in north India.

BACKGROUND & OBJECTIVES: In December 2019, a novel coronavirus (SARS-CoV-2) emerged in China and rapidly spread globally including India. The characteristic clinical observations and outcomes of this disease (COVID-19) have been reported from different countries. The present study was aimed to describe the clinico-demographic characteristics and in-hospital outcomes of a group of COVID-19 patients in north India. METHODS: This was a prospective, single-centre collection of data regarding epidemiological, demographic, clinical and laboratory parameters, management and outcome of COVID-19 patients admitted in a tertiary care facility in north India. Patient outcomes were recorded as death, discharge and still admitted. RESULTS: Data of 144 patients with COVID-19 were recorded and analyzed. The mean age of the patients was 40.1±13.1 yr, with 93.1 per cent males, and included 10 (6.9%) foreign nationals. Domestic travel to or from affected States (77.1%) and close contact with COVID-19 patients in congregations (82.6%) constituted the most commonly documented exposure. Nine (6.3%) patients were smokers, with a median smoking index of 200. Comorbidities were present in 23 (15.9%) patients, of which diabetes mellitus (n=16; 11.1%) was the most common. A significant proportion of patients had no symptoms (n=64; 44.4%); among the symptomatic, cough (34.7%) was the most common symptom followed by fever (17.4%) and nasal symptoms (2.15%). Majority of the patients were managed with supportive treatment with hydroxychloroquine and azithromycin given on a case-to-case basis. Only five (3.5%) patients required oxygen supplementation, four (2.8%) patients had severe disease requiring intensive care, one required mechanical ventilation and mortality occurred in two (1.4%) patients. The time to reverse transcription-polymerase chain reaction (RT-PCR) negativity was 16-18 days. INTERPRETATION & CONCLUSIONS: In this single-centre study of 144 hospitalized patients with confirmed COVID-19 in north India, the characteristic findings included younger age, high proportion of asymptomatic patients, long time to PCR negativity and low need for intensive care unit care.