Indian Guidelines on Nebulization Therapy.

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Caregiver's burden in pulmonary arterial hypertension: a clinical review.

Caregiver's burden is a multidimensional phenomenon affecting care-givers physically, emotionally and socially. It is critical to examine the burden of caregivers, because of the complex responsibility they have with their partners. There are relatively few studies that have examined factors linked with psychological burden amongst caregivers of pulmonary arterial hypertension (PAH) patients. Hence, it is pertinent to develop a good understanding of these factors and develop appropriate management strategies, modified to assist PAH caregivers.

Epidemiological Profile of Tobacco Users at Tobacco Cessation Centre: An Indian Experience.

Objective. Tobacco consumption continues to rise in India with about 34.6% of adult population being tobacco users. This study was done to evaluate the epidemiological profile of the tobacco users presenting to a Tobacco Cessation Centre (TCC) in Delhi. Methods. This is a retrospective observational study of subjects seen over a period of 10 years (2001-2010) at TCC of Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India. Information from a structured questionnaire filled by all tobacco users was pooled and analysed. Results. Of a total of 4493 subjects seen in the TCC, 4370 (97.3%) were males. 2704 (60.2%) subjects were smokers and remaining were users of smokeless tobacco. The highest number of subjects attending the clinic was between the age of 31 to 40 years. The mean age of starting tobacco use was 21 years. 2518 subjects started tobacco use due to "peer group pressure", while family history of tobacco use was observed in 2912 subjects. 3065 number of subjects attending the clinic were without any co-morbidity. Conclusions. Most of the subjects started tobacco use at a young age between 11 to 20 years. Peer pressure was the most common reason for initiation (56%). Most of the subjects (68.2%) had no co-morbidity. The present study observed that tobacco users probably want to quit smoking not only because of the consequences of co-morbidities but also because of the realisation of later harmful effects of continuing smoking.

Role of oxidative stress & transient receptor potential in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) affect millions of people worldwide and is known to be one of the leading causes of death. The highly sensitive airways protect themselves from irritants by cough and sneeze which propel endogenous and exogenous substances to minimize airway noxious effects. One noxious effect of these substances is activation of peripheral sensory nerve endings of nociceptor neurons innervating these airways lining thus transmitting dangerous signals from the environment to the central nervous system (CNS). Nociceptor neurons include transient receptor potential (TRP) ion channels, especially the vanilloid and ankyrin subfamilies, TRPV1/A1 which can be activated by noxious chemical challenges in models of airways disease. As oxidative stress may activate airways sensory neurons and contribute to COPD exacerbations we sought to review the role that TRP channel activation by oxidative signals may have on airway responses. i0 t would be prudent to target the TRP channels with antagonists and lower systemic oxidative stress with agents that can modulate TRP expression and boost the endogenous levels of antioxidants for treatment and management of COPD.

Consensus & Evidence-based INOSA Guidelines 2014 (First edition).

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

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

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

Comparative study of the efficacy and safety of theophylline and doxofylline in patients with bronchial asthma and chronic obstructive pulmonary disease.

BACKGROUND: Bronchial asthma and chronic obstructive pulmonary disease (COPD) are the major obstructive disorders that may contribute to the severity in individual patients. The present study was designed to compare the efficacy and safety of theophylline and doxofylline in patients with bronchial asthma and COPD. METHODS: A total of 60 patients, 30 each with bronchial asthma and COPD, were enrolled for the study. Each group of 30 patients received standard treatment for asthma and COPD. Each group was again subdivided into two with 15 patients each, who received theophylline or doxofylline in addition to standard therapy, for a period of 2 months. Each patient was followed up fortnightly for the assessment of efficacy parameters using a pulmonary function test (PFT), clinical symptoms and emergency drug use, and safety was assessed by recording adverse drug reactions. RESULTS: Both theophylline and doxofylline produced enhancements in PFT at different time intervals in both asthma and COPD patients. The maximum beneficial effects were seen at 6 weeks for asthma patients and at 8 weeks for COPD patients for both theophylline and doxofylline. CONCLUSIONS: The comparative study showed that doxofylline was more effective as evidenced by improvement in PFT as well as clinical symptoms, and reduced incidence of adverse effects and emergency bronchodilator use.

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

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

Chronic obstructive pulmonary disease.

The global prevalence of physiologically defined chronic obstructive pulmonary disease (COPD) in adults aged >40 yr is approximately 9-10 per cent. Recently, the Indian Study on Epidemiology of Asthma, Respiratory Symptoms and Chronic Bronchitis in Adults had shown that the overall prevalence of chronic bronchitis in adults >35 yr is 3.49 per cent. The development of COPD is multifactorial and the risk factors of COPD include genetic and environmental factors. Pathological changes in COPD are observed in central airways, small airways and alveolar space. The proposed pathogenesis of COPD includes proteinase-antiproteinase hypothesis, immunological mechanisms, oxidant-antioxidant balance, systemic inflammation, apoptosis and ineffective repair. Airflow limitation in COPD is defined as a postbronchodilator FEV1 (forced expiratory volume in 1 sec) to FVC (forced vital capacity) ratio <0.70. COPD is characterized by an accelerated decline in FEV1. Co morbidities associated with COPD are cardiovascular disorders (coronary artery disease and chronic heart failure), hypertension, metabolic diseases (diabetes mellitus, metabolic syndrome and obesity), bone disease (osteoporosis and osteopenia), stroke, lung cancer, cachexia, skeletal muscle weakness, anaemia, depression and cognitive decline. The assessment of COPD is required to determine the severity of the disease, its impact on the health status and the risk of future events (e.g., exacerbations, hospital admissions or death) and this is essential to guide therapy. COPD is treated with inhaled bronchodilators, inhaled corticosteroids, oral theophylline and oral phosphodiesterase-4 inhibitor. Non pharmacological treatment of COPD includes smoking cessation, pulmonary rehabilitation and nutritional support. Lung volume reduction surgery and lung transplantation are advised in selected severe patients. Global strategy for the diagnosis, management and prevention of Chronic Obstructive Pulmonary Disease guidelines recommend influenza and pneumococcal vaccinations.

Role of a pattern-based approach in interpretation of transbronchoscopic lung biopsy and its clinical implications.

BACKGROUND: Transbronchial lung biopsy (TBLB) is commonly performed for confirming the tissue diagnosis of diffuse parenchymal lung diseases (DPLDs). There is an urgent need to establish guidelines for interpretation of TBLB in order to improve its diagnostic utility. METHODS: We retrospectively studied 916 consecutive patients (494 males; mean age 49 years) who underwent TBLB over a 5-year period (July 2005 to July 2010) at Vallabhbhai Patel Chest Institute. RESULTS: In 615 (67.1%) procedures, material obtained during TBLB was adequate for histopathology interpretation. Pathological features evaluated in each case were: alveolar architecture, inflammatory infiltrate, interstitial fibrosis, atypical cells, pigment deposition, honey-comb change and fibroblast foci. The cases were categorised on the basis of histopathology into six patterns: (1) adequate biopsy without a specific diagnostic abnormality (n = 137, 22.3%); (2) acute pneumonitis (n = 29, 4.7%); (3) neoplasia (n = 109, 17.7%); (4) chronic interstitial inflammation with or without fibrosis (n = 138, 22.4%); (5) granulomatous inflammation, (n = 186, 30.2%); and (6) other specific causes (n = 16, 2.6%). Definitive diagnosis could be made after correlation of TBLB histopathology with clinical and radiological features in 55.3% cases. CONCLUSIONS: TBLB appears to be an important diagnostic tool for the diagnosis of DPLDs. The use of a pattern-based approach to TBLB adds to its diagnostic yield and can be helpful in cases where open lung biopsy is not available.

Regression equations for spirometry in children aged 6 to 17 years in Delhi region.

BACKGROUND: Most of the studies carried out in India to develop regression equations for spirometry in children are now several years-to-decades old and had used equipment and measurement protocols that have since changed. Prediction equations using the current standardisation protocols for spirometry are not available. The lung health of the population may have changed too. OBJECTIVE: To develop regression equations for spirometry for children aged 6 to 17 years of north Indian origin in Delhi region. METHODS: School children of north Indian origin, as determined by mother tongue and parentage, aged 6 to 17 years were screened by a health questionnaire and physical examination and those found "normal" underwent spirometry according to the standardised procedure recommended by the American Thoracic Society/European Respiratory Society (ATS/ERS) task force in 2005. Pearson's correlation analysis was carried out to identify the predictor variables for spirometric parameters. Prediction equations were developed using the multiple linear regression procedure. The independent variables were entered in sequence of height, age and weight. R2, adjusted R2 and R2 change, standard errors of the estimate (SEE), and estimates of regression coefficients were obtained and the goodness of fit was examined. RESULTS: Data was obtained in 365 boys and 305 girls. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1) peak expiratory flow rate (PEFR), forced expiratory flow rate at 50% and 75% exhalation of vial capacity (F50 and F75) and mean forced expiratory flow rate over the middle 50% of the vital capacity (F25-75) showed moderate to strong correlations with age, height and weight in both boys and girls. In both genders, the equations explained very high variability of FVC, FEV1 and PEFR as shown by the R2 values. The explained variability for flow rates was lesser, with that for F75 being the least. CONCLUSIONS: Regression equations for spirometry variables for children of north Indian origin in Delhi region have been developed. These represent the first such effort from India after the publication of the ATS/ERS task force 2005 guidelines on standardisation of spirometry.

Quality of asthma management in an urban community in Delhi, India.

BACKGROUND & OBJECTIVES: High prevalence and poor control of asthma make its management a major public health issue worldwide, especially in developing countries. Optimum review of asthma management in the community is essential to improve asthma control. This study was conducted to investigate the quality of asthma management, knowledge about asthma and quality of life of asthma patients referred to a public tertiary care chest hospital in Delhi. METHODS: Diagnosis of asthma was confirmed by symptoms and reversible spirometry in 50 referred patients on their first visit. Patients were interviewed using three questionnaires on quality of asthma management before visiting referral hospital, asthma knowledge and asthma quality of life (AQLQ). Correlation amongst quality of treatment, asthma quality of life, and asthma knowledge was also determined. RESULTS: Findings revealed that only 60 per cent of patients were informed about their disease, and 10 per cent had undergone lung function tests previously. Only 44 per cent of patients were prescribed inhalers. None were provided with any educational material. Patients had poor knowledge of aetiology, pathophysiology, medication and how to assess the severity of their asthma. The mean scores in AQLQ indicated a moderate degree of impairment in quality of life. INTERPRETATIONS & CONCLUSIONS: This study provides evidence of unsatisfactory asthma management and patient-doctor interaction as patients had limited knowledge of asthma disease, its management and had poor quality of life as measured by a standardized questionnaire. Thus, there is need to implement suitable interventions to improve asthma management according to standard treatment guidelines in the community.

Breath carbon monoxide level of non-smokers exposed to environmental tobacco smoke.

BACKGROUND: Environmental tobacco smoke (ETS) exposure is a health hazard for non-smokers. OBJECTIVE: To measure breath carbon monoxide (CO) levels of non-smoking subjects exposed to ETS and of non-smoking subjects not exposed to ETS. RESULTS: The study was conducted with the help of a pre-designed questionnaire. One hundred male subjects were selected for the study; group I consisted of 50 non-smokers (waiters in hotels/restaurants/bars) exposed to ETS and group II consisted of 50 non-smokers not exposed to ETS. All subjects underwent clinical examination. Breath CO levels of both the groups were measured by the Mini Smoklyzer. The mean breath CO level (ppm) was higher in group I compared to group II (9.18 +/- 2.84 versus 4.56 +/- 1.62; p < 0.001). The mean breath CO level was also significantly higher in ETS exposed subjects who worked for more than nine hours a day in bars, restaurants and hotels (p = 0.018) and in subjects suffering from respiratory diseases (p < 0.001) compared to normal subjects. CONCLUSION: The abnormally high level of breath CO observed in passive smokers exposed to ETS may suggest that, these subjects may be prone to develop the tobacco related diseases.

Anti-oxidant treatment in obstructive sleep apnoea syndrome.

PURPOSE: To investigate whether oral intake of N-acetylcysteine (NAC) is a treatment option in patients with obstructive sleep apnoea syndrome (OSAS). METHODS: Twenty patients with OSAS were enrolled in the study. After polysomnography (PSG), they were randomly assigned to receive a placebo (n = 10) and NAC (n = 10). A repeat PSG was done after the treatment period of 30 days. Fasting venous samples were collected for various biochemical analysis. RESULTS: In the patients of NAC group, compared to their baseline values, slow wave sleep as sleep percent time (27.9 +/- 2.7 vs 42.3 +/- 4.2; p < 0.01) and sleep efficiency (90.8 +/- 1.3 vs 94.4 +/- 1.5; p < 0.05) improved considerably. The apnoea-hypopnoea index (61.2 +/- 8.5 vs 43.1 +/- 8.6; p < 0.05), apnoea related arousals (22.2 +/- 7.6 vs 11.6 +/- 4.7; p < 0.05), longest apnoeic episode duration (seconds) (54.9 +/- 7.1 vs 37.8 +/- 5.6; p < 0.01), oxygen desaturation events per hour (51.8 +/- 7.7 vs 37 +/- 7.8; p < 0.01) and epworth sleepiness score (16.6 +/- 0.8 vs 9.2 +/- 0.9; p < 0.001) decreased significantly. The relative snore time (%) (10.2 +/- 2.9 vs 4.9 +/- 1.9; p < 0.01), number of snore episodes (63.8 +/-23.9 vs 28.2 +/- 9.9; p < 0.05) and duration of longest snore episode (min) (2.5 +/- 0.7 vs 0.6 +/- 0.1; p < 0.05) also decreased significantly. Such responses were not evident in the placebo group. N-acetylcysteine produced significant decrease in lipid peroxidation and increase in total reduced glutathione. CONCLUSIONS: Oral NAC administration appears to have a therapeutic potential in the treatment of OSAS. It is proposed that long-term treatment with NAC in patients with OSAS may reduce their dependency on continuous positive airway pressure therapy.

Systemic inflammation and its response to treatment in patients with asthma.

BACKGROUND: Asthma is an obstructive airway disease characterized by airway inflammation. OBJECTIVE: To measure systemic inflammation in asthma patients, and to assess the effect of treatment on systemic inflammation. METHODS: In 30 newly diagnosed non-randomized adult asthma patients we measured systemic inflammation markers (serum high-sensitivity C-reactive protein, total leukocyte count, and erythrocyte sedimentation rate) before and after a 6-week standard treatment with inhaled steroids and inhaled ß(2) agonist. The comparison group comprised 20 healthy control subjects. All the subjects were non-smokers. RESULTS: The measured systemic inflammation markers were higher in the asthma patients: high-sensitivity C-reactive protein 4.8 ± 6.0 mg/dL vs 1.5 ± 1.4 mg/dL, P < .001; total leukocyte count 8,936 ± 2,592 cells/µL versus 7,741 ± 1,924 cells/µL, P < .001; erythrocyte sedimentation rate 24.8 ± 12.3 mm/h versus 15.3 ± 6.5 mm/h, P < .001. In the asthma patients, high-sensitivity C-reactive protein negatively correlated with percent-of-predicted FEV(1) (r = -0.64, P = .001), percent-of-predicted forced vital capacity (FVC) (r = -0.39, P = .03), FEV(1)/FVC% (r = -0.71, P < .001), and percent-of-predicted forced expiratory flow during the middle half of the FVC maneuver (FEF(25-75)) (r = -0.51, P = .004). Total leukocyte count negatively correlated with percent-of-predicted FEV(1) (r = -0.64, P = .001), percent-of-predicted FEV(1)/FVC (r = -0.74, P < .001), and percent-of-predicted FEF(25-75) (r = -0.58, P = .001). Body mass index positively correlated with high-sensitivity C-reactive protein (r = 0.65, P < .001). Multiple linear regression showed significant correlation of high-sensitivity C-reactive protein (r(2) = 0.75) with age (ß = 0.31, P = .008), body mass index (ß = 0.99, P = .001), family size (ß = 0.33, P = .008), and weight (ß = -0.45, P = .01). The systemic inflammation markers decreased significantly (P < .001 for all comparisons) after 6 weeks of treatment: high-sensitivity C-reactive protein decreased from 4.8 ± 6.0 mg/dL to 2.4 ± 5.4 mg/dL, total leukocyte count decreased from 8,936 ± 2,592 cells/µL to 6,960 ± 1,785 cells/µL, and erythrocyte sedimentation rate decreased from 24.8 ± 12.3 mm/h to 15.8 ± 10.1 mm/h. CONCLUSIONS: Inhaled steroids plus inhaled ß(2) agonist significantly reduced systemic inflammation in asthma patients.

Role of nitric oxide in the diuresis and natriuresis occurring in patients with obstructive sleep apnoea syndrome.

OBJECTIVE: To determine whether nitric oxide (NO) has any role in the diuresis and natriuresis observed in patients with obstructive sleep apnoea syndrome (OSAS). METHODS: We measured 12-hour urine volume in the day and in the night in patients with OSAS (n=20) and determined the concentrations of urinary sodium and nitrate. The frequency of urination in the night was also noted. The measurements were done again after two nights of continuous positive airway pressure (CPAP) therapy and after putting the patients on oral anti-oxidant treatment (vitamin C-100 mg BD and vitamin E-400 IU BD) for 45 days. Ten healthy normal subjects underwent the same protocol except the CPAP therapy. RESULTS: In patients with OSAS, the night urine volume and sodium concentration were similar and the nitrate levels were higher compared to those in the day. After CPAP therapy, while the urine volume and sodium concentration decreased, the nitrate level became similar to that in the day. Such effects were not observed after anti-oxidant treatment. The frequency of urination was decreased in both the instances. The effects observed after CPAP therapy were similar to those observed in control subjects with or without anti-oxidant treatment. CONCLUSION: Renal NO promotes diuresis and natriuresis in patients with OSAS.

Influence of codeine on lobeline-induced respiratory reflexes and sensations and on ventilation with exercise in healthy subjects.

In 15 healthy subjects, the effect of 60 mg oral codeine and placebo was examined on intravenously injected lobeline-elicited respiratory reflexes and sensations. Its influence was also studied on ventilation and appearance of distressful respiratory sensations with modest but incremental exercise. After placebo, tachypnoea and respiratory sensations were evoked with 12.1 ± 1.9 µg/kg of lobeline i.v. (mean threshold dose) and after codeine, by significantly higher doses i.e., 18.0 ± 3.1 µg/kg (P < 0.05). Additionally after codeine, in response to incremental doses of lobeline the respiratory reflex was notably attenuated and the magnitude of respiratory sensations, subdued. Dry cough seen in 66% of the subjects with suprathreshold doses of lobeline i.e., 22.0 ± 3.4 µg/kg (mean), appeared post codeine, with significantly higher doses i.e., 27.0 ± 3.9 µg/kg (mean) (P < 0.05) and in a fewer subjects (60%). Mean increase in minute ventilation at the end of 8 min of incremental treadmill walking after codeine was 21% less than after placebo (P < 0.05); 60% of the subjects continued to walk for an additional 4 min and the onset of respiratory discomfort was delayed by 1-5 min. This is the first report of an attenuation of lobeline-elicited respiratory reflexes and sensations that are attributable to J receptors (pulmonary C fibres) by a pharmacological entity. It also suggests that codeine decreased these receptors' known contribution to respiratory augmentation and motor inhibition during exercise, which was seen as a delay in the onset of, and a decrease in the magnitude of respiratory discomfort during treadmill walking and an increase in the duration walked by more than half the subjects.

Assessment of protective role of polyherbal preparation, Livina, against anti-tubercular drug induced liver dysfunction.

The present study evaluated the possible protective role of Livina (a polyherbal preparation) against anti-tubercular therapy (ATT)-induced liver dysfunction in patients of pulmonary tuberculosis. Patients were given intensive phase treatment with 4-drugs (rifampicin, INH, pyrazinamide and ethambutol) used for anti-tubercular therapy for 2 months, followed by a 4-month continuous phase treatment with 2 drugs (rifampicin and INH) under clinical advice and supervision. Both qualitative and quantitative measures of liver function were assessed, at different time intervals, before and after ATT. Analysis of data showed that the incidence of qualitative manifestations of liver dysfunction were greater in the placebo treated group as compared to the test drug group. None of the patients of either group showed clinical jaundice. Most signific changes ant were observed in the SGOT and SGPT levels in the placebo group, wherein the levels of both enzymes were higher at 4 and 8 weeks post-ATT, as compared to the respective baseline (0 week) values. When Livina (2 capsules twice daily) was given with ATT drugs, incidence of qualitative manifestation of liver dysfunction was insignificant and SGOT and SGPT levels were also significantly lower than the placebo+AITT drugs treated group. These results indicate that the test drug (Livina) was efficacious, against ATT-induced hepatic dysfunction in patients of pulmonary tuberculosis.