Efficacy of different respiratory supports to prevent hypoxia during flexible bronchoscopy in patients of COPD: a triple-arm, randomised controlled trial.

BACKGROUND: Patients with chronic-obstructive-pulmonary-disease (COPD) undergo bronchoscopy for various reasons, and are at relatively higher risk of complications. This study evaluated the efficacy of non-invasive ventilation (NIV) and high-flow-oxygen-therapy (HFOT) compared with conventional-oxygen-therapy (COT) in patients with COPD undergoing bronchoscopy, to prevent hypoxia. METHODS: It was a triple-arm, open-label, randomised controlled trial. Ninety patients with COPD were randomly assigned into three intervention arms in 1:1:1 ratio. The incidence of hypoxia, lowest recorded oxygen saturation measured by plethysmography (SpO2), ECG, patient vitals and comfort levels were assessed. RESULTS: Mean age of the study population was 61.71±7.5 years. Out of 90 cases enrolled, 51, 34 and 5 were moderate, severe and very-severe COPD, respectively, as per GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification. Rest of the baseline characteristics were similar. SpO2 during flexible bronchoscopy (FB) was lowest in COT group (COT: 87.03±5.7% vs HFOT: 95.57±5.0% vs NIV: 97.40±1.6%, p<0.001). Secondary objectives were similar except respiratory-rate (breaths-per-minute) which was highest in COT group (COT: 20.23±3.1 vs HFOT: 18.57±4.1 vs NIV: 16.80±1.9, p<0.001). Whereas post FB partial of oxygen in arterial blood was highest in NIV group (NIV: 84.27±21.6 mm Hg vs HFOT: 69.03±13.6 mm Hg vs COT: 69.30±11.9 mm Hg, p<0.001). Post FB partial pressure of carbon dioxide in arterial blood was similar in the three arms. Operator's ease-of-performing-procedure was least in the NIV group as assessed with Visual Analogue Scale (p<0.01). A higher number of NIV group participants reported nasal pain as compared with the other two arms (p<0.01). CONCLUSION: NIV and HFOT are superior to COT in preventing hypoxia during bronchoscopy, but NIV is associated with poor patient-tolerance and inferior operator's ease of doing procedure. TRIAL REGISTRATION NUMBER: CTRI/2021/03/032190.

Role of Janus Kinase inhibitors in the management of pulmonary involvement due to Long COVID-19 disease: A case control study.

OBJECTIVES: Ongoing symptomatic coronavirus disease 2019 (OSC) is defined as persistent symptoms beyond 4 weeks of acute illness. OSC leads to prolonged hospitalization and oxygen dependence. We aimed to find the outcome of Janus kinase inhibitors (JAKi) as a steroid-sparing agent to treat OSC. METHODS: In this single-center case-controlled study comparing JAKi and corticosteroids in OSC cases, data of 41 cases out of 86 were included - 21 in the JAKi group and 20 in the corticosteroid group from 4 weeks of acute illness to the next 4 weeks. Clinical parameters and inflammatory markers were recorded. The primary outcome was to compare the proportion of patients who were able to maintain oxygen saturation ≥95% with any oxygen supplementation in the two groups. RESULTS: The baseline clinical and demographic characteristics were similar in the two groups. The age was 53.65 ± 9.8 years and 51.48 ± 14.0 years in the corticosteroid group and JAKi group, respectively. At the baseline, 85% of patients in the corticosteroid group and 85.8% in the JAKi group were on oxygen support. The most common symptom in both groups was breathlessness followed by cough. Twenty percent of patients in the JAKi group received baricitinib and the remaining were given tofacitinib. At the time of follow-up, the majority of cases had a significant reduction in C-reactive protein (CRP) and D-dimer; however, the change in CRP and D-dimer was similar in both groups. The number of patients off oxygen support at 4 weeks was higher in the JAKi group (85% in the corticosteroid group vs. 95.2% in the JAKi group, P = 0.269), and the median time to liberation from oxygen support was significantly lower in JAKi group (19 days in corticosteroid group vs. 9 days in JAKi group, P < 0.001). The frequency of any adverse event was also higher in the corticosteroid group (70% vs. 23.8%, P = 0.003). CONCLUSION: JAKi can be used as immunomodulatory drugs in hypoxic OSC cases having evidence of ongoing inflammation.

Nonsmoker COPD represents a clinically Distinct Phenotype: A Prospective Observational Study.

BACKGROUND: Chronic obstructive lung disease (COPD) has been characterized as a smoker's disease, which has resulted in the usual exclusion of never-smokers from COPD studies. It is now recognized that never-smokers account for nearly one-fourth of all COPD cases, and thus airflow limitation in never-smokers needs further evaluation. Our study aims to elucidate the clinical and physiological aspects of COPD in nonsmokers and to compare smokers and nonsmokers with COPD. MATERIALS AND METHODS: A total of 200 naïve sequential patients with COPD were recruited. The severity of airflow limitation in COPD patients was defined as per Global Initiative for COPD (GOLD) 2019 criteria, and the severity of breathlessness was assessed by the modified Medical Research Council (MRC) dyspnea scale. Data was collected using a patient pro forma, including risk factors for COPD and detailed clinical history. Phenotypic differences along with biomass exposure between never-smokers and smokers were analyzed. RESULTS: Compared to smokers, never-smokers presented at a younger age (55.69 ± 11.5 years; p < 0.001), with a longer duration of dyspnea (5.05 ± 4.96 vs 7.35 ± 6.98 years, p < 0.01). Chest radiographs revealed hyperinflation in a higher number of smokers as compared to never-smokers (82.9 vs 64.6%, p < 0.05). On spirometry evaluation, smokers were found to have significantly poorer lung function [forced expiratory volume in first second (FEV1) 40.36 ± 17.76%; forced vital capacity (FVC): 58.16 ± 17.02%] as compared to never-smokers (FEV1: 47.1 ± 16.47%; FVC: 67.38 ± 17.02%) with p < 0.05. With respect to severity at presentation, most (45.8%) never-smokers presented with stage 2 COPD as compared to the majority of smokers (46.7%) who presented with stage 3 COPD (p-value of <0.05). Absolute eosinophil count (AEC) and eosinophil proportion in total leucocyte count (TLC) was significantly higher in never-smokers as compared to the smokers (232 ± 204.2 vs 309 ± 238.8, p < 0.05). Risk factor analysis showed mean biomass exposure index was significantly higher in never-smokers as compared to smokers (56.02 vs 6.28; p-value of <0.001). CONCLUSION: Compared to smokers, COPD in never-smokers presents at a younger age, with a longer duration of dyspnea and higher eosinophil count. Biomass exposure is one of the major contributors to etiologies for COPD in nonsmokers.

Dynamic assessment of oropharynx with ultrasonography as a screening tool for obstructive sleep apnea.

Ultrasonography is an easily available and portable tool to assess the dynamic changes in the upper airway and surrounding soft tissue. This study aimed to evaluate the utility of oropharynx ultrasonography as a screening tool for obstructive sleep apnea (OSA). The study sequentially enrolled overweight individuals (body mass index >25 kg/m2 ) and subjected them to OSA screening tools (Berlin questionnaire, Epworth Sleepiness Scale and STOP-Bang scores), ultrasonography of the oropharynx followed by overnight polysomnography. A total of 30 healthy individuals were also recruited as controls. Detailed dynamic and static ultrasonography measurements of the oropharynx and surrounding tissue were done. The diagnostic ability of various ultrasonography parameters to detect OSA was determined using receiver operating characteristic curve analysis. A total of 63 subjects were enrolled, with 33 in the OSA group and 30 in non-OSA overweight group. All baseline characteristics were similar in the two groups. Except for the dynamic measurements of oropharynx (Retropalatal% change-inspiration, retropalatal% change-Muller manoeuvre, retroglossal% change-inspiration, and retroglossal% change-Muller manoeuvre) all other parameters were similar in the OSA and non-OSA overweight subjects. The area under the receiver operating characteristic curve was highest for retropalatal% change-inspiration: 0.989, followed by retropalatal% change-Muller manoeuvre: 0.988. Both were also significant predictors of OSA with odds ratios of 0.338 (p = 0.003; 95% confidence interval [CI] 0.164-0.696) and 0.346 (p = 0.018; 95% CI 0.143-0.837), respectively. Ultrasonography provides a near complete picture of the dynamic changes and collapsibility of the oropharynx and can be an effective tool in screening for OSA.

The role of diaphragmatic thickness measurement in weaning prediction and its comparison with rapid shallow breathing index: a single-center experience.

BACKGROUND: Acute respiratory failure (ARF) is commonly managed with invasive mechanical ventilation (IMV). The majority of the time that a patient spends on IMV is in the process of weaning. Prediction of the weaning outcome is of paramount importance, as untimely/delayed extubation is associated with a high risk of mortality. Diaphragmatic ultrasonography is a promising tool in the intensive care unit, and its utility in predicting the success of weaning remains understudied. METHODS: In this prospective-observational study, we recruited 54 ARF patients on IMV, along with 50 healthy controls. During a spontaneous breathing trial, all subjects underwent diaphragmatic ultrasonography along with a rapid shallow breathing index (RSBI) assessment. RESULTS: The mean age was 41.8±17.0 and 37.6±10.5 years among the cases and control group, respectively. Demographic variables were broadly similar in the two groups. The most common cause of ARF was obstructive airway disease. The average duration of IMV was 5.41±2.81 days. Out of 54 subjects, 45 were successfully weaned, while nine patients failed weaning. Age, body mass index, and severity of disease were similar in the successful and failed weaning patients. The sensitivity in predicting successful weaning of percent change in diaphragmatic thickness (Δtdi%) >29.71% was high (93.33%), while specificity was 66.67%. The sensitivity and specificity of mean diaphragmatic thickness (tdi) end-expiratory >0.178 cm was 60.00% and 77.78%, respectively. RSBI at 1 minute of <93.75 had an equally high sensitivity (93.33%) but a lower specificity (22.22%). Similar results were also found for RSBI measured at 5 minutes. CONCLUSIONS: During the weaning assessment, the purpose is to minimize both premature as well as delayed extubation. We found that diaphragmatic ultrasonography, in particular Δtdi%, is better than RSBI in predicting weaning outcomes.

Left Adrenal Gland Sampling Through Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B FNA): A New Route and a New Challenge.

Metastasis to adrenal glands from primary pulmonary carcinoma is quite a common occurrence. In most cases, the diagnosis is made based on an imaging evaluation done because of chronic non-specific pulmonary symptoms. Further evaluation to determine the type of carcinoma is done using histopathological evaluation of the primary lung lesion. Here, we have described a case of a 60-year-old man who presented with chest pain and was incidentally detected with a lower lung mass and a bulky left adrenal gland in the upper abdominal cuts on a CT of the thorax. As the evaluation of the fine needle aspiration (FNA) sample from lung lesion couldn't be successfully performed, sampling from the left adrenal gland was attempted under the guidance of conventional endoscopic ultrasound using an endobronchial ultrasound probe (EUS-B). When the technique failed to localise the left adrenal gland, a modification was made and the gland was localised using the spleen as a marker. This case further presented a challenge, when due to the unfolding of rugae, the FNA needle wasn't able to reach up to the left adrenal gland. Further adjustment was made and the maximum depth of the gland from the margin was measured and the needle was fully freed. Multiple jabs were made and sampling was successfully done. Cellblock confirmed the presence of adenocarcinoma of pulmonary origin, positive for thyroid transcription factor 1 (TTF-1). The patient remained stable and did not present with any early or late post-procedural complications. The patient was started on appropriate chemotherapy for the disease. He has received three cycles of carboplatin and pemetrexed till now and is doing well.

Perception of healthcare workers towards ethical aspects of responsiveness of COVID 19 outbreak: A cross-sectional study.

Introduction: COVID-19 has spread all over the world and most of the countries are still grappled with the Pandemic. Health-care-workers (HCWs) being the frontlines during such pandemics have different beliefs and faiths with regards to ethical aspects of preparations. Methodology: In order to study the perception of HCW about ethical aspects of COVID-19, a cross-sectional study was done in a tertiary-care-teaching hospital. A pretested questionnaire was circulated among the participants on a digital platform. Results: The HCWs were divided over many statements, like if COVID-19 was more hype than reality (45.77% disagreed and 43.25% agreed). 57.44% of participants either agreed or strongly agreed that the treatment of non-COVID-19 cases suffered due to arrangements made for COVID-19 cases. When the responses received against individual statements were compared with various other socio-demographic variables as a denominator, various interesting results were revealed. There was a significant difference of opinion among the participating HCWs (P < 0.05). Conclusion: Differences of the opinions had their relationships to demographic characteristics of the subjects as well as related to perceived knowledge of COVID-19.

COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A review.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus responsible for the pandemic coronavirus disease 19 (COVID-19). It has significant impact on human health and public safety along with negative social and economic consequences. Vaccination against SARS-CoV-2 is likely the most effective approach to sustainably control the global COVID-19 pandemic. Vaccination is highly effective in reducing the risk of severe COVID-19 disease. Mass-scale vaccination will help us in attaining herd immunity and will lessen the negative impact of the disease on public health, social and economic conditions. The present pandemic stimulated the development of several effective vaccines based on different platforms. Although the vaccine is safe and efficacious, rare cases of thrombosis and thrombocytopenia following the use of vaccination with the ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India) or the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) have been reported globally. This review focussed on the definition, epidemiology, pathogenesis, clinical features, diagnosis, and management of vaccine associated thrombosis.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics.

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience.

BACKGROUND: The second wave of COVID-19 pandemic was not only associated with a rapid and severe surge in the number of cases but also limited availability of recommended medicines. Baricitinib has been known to reduce recovery time in COVID-19 pneumonia in association with remdesivir. Tofacitinib, with limited evidence, was used in severe COVID-19 pneumonia based on its similarity of action with baricitinib. METHODS: Data of all patients admitted to the COVID-19 intensive care unit in the month of April were accessed and analyzed. Data of patients who were on other immunomodulators, invasive ventilation, or suffering from end-stage organ diseases were excluded from the analysis. RESULTS: Out of 73 patients, data of 50 were analyzed. Twenty-five received tofacitinib and the other 25 were managed with standard of care. Age, comorbidities, and gender distribution between the two groups were similar. On day 7 of admission, the change in SpO2/FiO2 ratio was 1.26 ± 1 and 0.72 ± 1 in the tofacitinib group and control group, respectively. Similarly, a higher number of subjects in the control group showed worsening in the World Health Organization (WHO) ordinal scale (36 vs 12%, p = 0.01). The clinical objective improvement was similar in the two groups. The intubation rates in the tofacitinib group were significantly lower than that in the control group (32% vs 8%, p = 0.034). CONCLUSION: Tofacitinib, in this retrospective single-center experience, was found to be associated with reduced intubation rates and reduced worsening in the WHO ordinal scale. There was no difference in mortality in the two groups. HOW TO CITE THIS ARTICLE: Singh PK, Lalwani LK, Govindagoudar MB, Aggarwal R, Chaudhry D, Kumar P, et al. Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience. Indian J Crit Care Med 2021;25(10):1108-1112.

Assessment of knowledge of COVID-19 among health care workers-a questionnaire-based cross-sectional study in a tertiary care hospital of India.

BACKGROUND: Health Care Workers (HCW) are among the primary stakeholders and front liners in the fight against COVID-19. They are in direct contact with the patients as primary caregivers and, therefore, are at a higher risk of infection. This Pandemic offers a unique opportunity to explore the level of knowledge among ground-level HCWs during this global health crisis. OBJECTIVE: We conducted this study to assess the knowledge and awareness among HCW regarding the COVID-19 Pandemic in a tertiary care hospital. METHODS: It was a cross-sectional study done on HCW comprising faculty, senior residents, junior residents, demonstrators, and nursing staff of various specialties directly involved in the care of suspected/confirmed COVID-19 patients. A pretested questionnaire consisting of 20 questions was used as a study tool and was circulated through the digital platform. RESULTS: There were a total of 437 respondents. In the subgroup analysis, the respondents in the age group of 55-64 years had a higher mean knowledge score, followed by the respondents in the age group of 18-24 years. For years of experience, the mean knowledge score varied from 13.89 (10-20 years of experience) to 13.83 (5-10 years of experience). The mean knowledge score was the highest for consultants (14.10), followed by Resident Doctors (13.96). CONCLUSIONS: This study has shed some critical clues for further research and interventions. Firstly, as health care workers are probably learning about COVID-19 from their practical exposure rather than formal teaching, it is pertinent to address this issue through well-planned formal sessions of training workshops and lectures.

Assessment of pandemic (COVID-19) preparedness in a teaching hospital in northern India using available (CDC-Atlanta) checklist.

BACKGROUND: Hospitals are at the forefront of dealing infectious public health emergencies. Recently, COVID-19 has been declared as pandemic by the World Health Organization. Dealing with COVID-19 pandemic requires high intensity of administrative activity. OBJECTIVE: We conducted this study to assess and compare, objectively, hospital preparedness with available Centre of Disease Control and Prevention (CDC) standards. METHODS: CDC has issued checklist for the assessment of hospital preparedness for COVID-19 pandemic, globally. This list contains 10 elements with sub-sections. We objectified the same and scored the hospital preparations accordingly. Various financial efforts made by the hospital to procure COVID19-specified items was also recorded. RESULTS: As per the CDC checklist, the hospital scored 197 points (72.06%) out of 270 points with highest points in element two and eight. Element two is for the development for written COVID-19 plan. Element eight consists of addressing the occupational health of healthcare workers. Lowest scoring was in the element seven represented visitor access and movement within facility. During the study period, the hospital procured items of approximately 55 lakhs. In the study period, doctors, nursing staff, housekeeping staff, and security staff were channelized for doing COVID-19 duties. CONCLUSIONS: We obtained a score above 70% (good) which is quite encouraging, and we concluded that pandemic preparations in hospitals are necessary and it can be assessed objectively against prevailing standards. It is important in poor countries like India where spending on healthcare is minimal compared to other countries. Additionally, this assessment can be used to guide us further changes in policies and identifying the gaps in pandemic preparedness in hospitals which require special attention.

COVID-19 and coagulopathy.

The SARS-CoV-2 is a new coronavirus responsible for the COVID-19 disease and has caused the pandemic worldwide. A large number of cases have overwhelmed the healthcare system worldwide. The COVID-19 infection has been associated with a heightened risk of thromboembolic complications. Various mechanisms are leading to the high thrombotic risk in COVID-19 patients such as inflammation, endotheliitis, hyperviscosity, and hypercoagulability. We searched PubMed, EMBASE, and CINAHL from January 2020 to December 2020. We used the following search terms: COVID-19, coagulopathy, and thrombosis. We reviewed the epidemiology, clinical features, mechanisms, and treatment of COVID-19-associated coagulopathy.

Correlation of PaCO2 and ETCO2 in COPD Patients with Exacerbation on Mechanical Ventilation.

Introduction: Chronic obstructive pulmonary disease (COPD) patients in hypercapnic respiratory failure require multiple arterial blood gas (ABG) analysis for monitoring. It is a painful, invasive, and expensive investigation. This study was aimed at finding an agreement between end-tidal carbon dioxide (ETCO2, a noninvasive modality) and arterial carbon dioxide (PaCO2) in COPD patients with acute exacerbation on mechanical ventilation. Materials and methods: A prospective observational study was conducted in COPD patients who required mechanical ventilation. ETCO2 was recorded by mainstream capnography along with ABG analysis. An agreement between PaCO2 and ETCO2 was assessed. The effect of various factors on correlation was also studied. Results: A total of 100 patients with COPD in hypercapnic respiratory failure were included. Seventy-three percentage of patients were managed on invasive mechanical ventilation (IMV). The mean ETCO2 and PaCO2 were 48.66 ± 15.57 mm Hg and 75.52 ± 21.9 mm Hg, respectively. There was a significant correlation between PaCO2 and ETCO2 values (r = 0.82, 95% confidence interval of r = 0.78-0.86, p <0.0001). The Bland-Altman analysis shows the mean bias as -19.4 (95% limits of agreement = -40.0-1.1). Pearson's correlation coefficient was 0.84 in intubated patients and 0.58 in patients on noninvasive ventilation (NIV). Pearson's correlation coefficient between PaCO2 and ETCO2 in subjects with consolidation, cardiomegaly, hypotension, and raised pulmonary artery pressures was 0.78, 0.86, 0.85, and 0.86, respectively. Conclusion: Mainstream ETCO2 measurement accurately predicts the PaCO2 in COPD patients on IMV. However, for patients on NIV, ETCO2 is insufficient in monitoring PaCO2 levels due to weak correlation. Clinical significance: ETCO2 can be used as a noninvasive modality in intensive care unit for monitoring the PaCO2 in COPD patients on IMV. This can reduce the requirement of arterial blood sampling to a minimum number, in turn, reducing the cost of the treatment and discomfort to the patients. How to cite this article: Tyagi D, Govindagoudar MB, Jakka S, Chandra S, Chaudhry D. Correlation of PaCO2 and ETCO2 in COPD Patients with Exacerbation on Mechanical Ventilation. Indian J Crit Care Med 2021;25(3):305-309.

COVID-19: Winter is COMING!

Coronavirus disease-2019 (COVID-19) pandemic has battered the healthcare system of India recently. Though the mortality rate is low but the mortality itself is high. In this issue, dedicated to COVID-19, the authors have presented a concise and directed look at the pieces of evidence for COVID-19. Today, there is a plethora of information available on COVID-19 but the same does not translate into true knowledge. This issue serves as the one-point reference for pieces of evidence on various critical aspects of COVID-19. As winters are approaching and air pollution will again be bothering the healthcare system, these times are vital for preparing ourselves and resources for a long and exhaustive battle. How to cite this article: Chaudhry D, Kumar P, Singh PK, Govindagoudar MB. COVID-19: Winter is COMING! Indian J Crit Care Med 2020;24(Suppl 5):S223-S224.

Mediastinal tubercular lymph node eroding into pericardium causing acute pyopericardium and cardiac tamponade.

Cardiac tamponade due to tuberculosis is a well-known complication. However, acute erosion of TB lymphadenitis and its caseous material into the pericardium causing pericardial tamponade is rare. We describe a case of extensive mediastinal tubercular lymph node mass in which the caseous necrotic material found its way into pericardial sac causing acute pyopericardium and cardiac tamponade.