Management of COVID-19: A comprehensive and practical approach.

Since the beginning of Corona Virus Disease (COVID) pandemic, there has been lack of clarity about the management protocols in spite of frequently updated national and international guidelines. Irrational use of unproven therapies has not been helpful in improving treatment outcomes. Early use of high-dose steroids or late use of antiviral medicines might have caused more harm than the benefit. There is also lot of fear about post-COVID fibrosis leading to extended use of steroids and antifibrotics. We reviewed the available COVID guidelines and treatment protocols in the light of scientific evidence generated over last 2 years by a systematic literature search using various databases (PubMed, Google Scholar, MEDLINE, UpToDate, Embase, and Web of Science). This article presents a comprehensive approach to the diagnosis, appropriate investigations, their interpretations, and use of specific therapies according to the stage of disease.

Clove stalk aspiration: An unusual cause of chronic cough.

Foreign body aspiration in adults is one of the uncommon causes of chronic cough and may be missed if the patient already has a known cause of chronic cough, but the same is not responding to therapy. A 72-year-old male patient, a known case of allergic rhinitis, presented with a history of cough for 6 months. There was unsatisfactory response to treatment with antibiotics, inhalational corticosteroids, oral corticosteroids, bronchodilators, and antireflux treatment. High-resolution computed tomography was normal. However, fiber optic bronchoscopy revealed a foreign body in the right lower lobe, which was removed and was identified as clove stalk. This led to rapid relief of symptoms. Clove stalk aspiration is an unusual foreign body causing chronic cough, which has not yet been reported.

Intrapleural Fibrinolytic Therapy in Loculated Pleural Effusions.

About 36% to 57% of bacterial pneumonias develop parapneumonic effusion. When the chest tube is correctly positioned as evidenced by postero-anterior and lateral chest radiographs and there is a significant amount of pleural fluid, the major reasons for failed drainage are multiple pleural space loculations or tube obstruction by thick and viscous fluid. The various modalities of treatment available for loculated pleural effusion are: saline flushes, placing one or more catheters in loculi under image guidance, video assisted thoracoscopic surgery (VATS), standard thoracotomy with drainage of empyema and decortication. The first two modalities are not so effective in improving drainage. The last two surgical modalities are more invasive, not easily available and, if available, are not affordable by majority of patients in the developing countries like India. The fibrinolytic agents, if used early in loculated pleural effusions, break loculations and early pleural peel thereby facilitating pleural space drainage.

A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections.

BACKGROUND: Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage. OBJECTIVE: To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies. METHODS: A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution. RESULTS: There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases. CONCLUSIONS: Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

Early detection of chronic obstructive pulmonary disease in asymptomatic smokers using spirometry.

BACKGROUND: Smokers with suspected COPD seek medical attention when they become dyspnoeic on mild to moderate exertion, but by than half of the ventilatory reserves are lost irreversibly. Hence it seems logical to diagnose COPD early before development of significant symptoms. Since smoking cessation in early COPD is found to reduce rapid decline of ventilatory function in smokers, its early detection in asymptomatic smokers is likely to motivate smokers to make an attempt to quit smoking thereby halting its progression to more advanced stage. MATERIAL AND METHODS: The selection of subjects was done by high risk population screening in various military institutions in and around Pune city of Maharashtra. Inclusion criteria included regular smokers, 30 years of age and above with no significant respiratory symptoms except for occasional cough and willing to undergo spirometry. RESULTS: A total of 460 individuals were evaluated by spirometry. Overall airway obstruction was seen in 58 (12.60%) subjects. Mild obstruction was seen in 40 (68.9%) and moderate obstruction in 18 (31%) subjects. Airway obstruction was seen in 24 (8.82%) individuals who were less than 40 years of age and in 34 (18%) who were more than 40 years of age (p < 0.005). Obstruction was noticed in 42 (24.70%) out of 170 subject with smoking index > 200 and 16 (5.51%) out of 290 subjects with smoking index of < 200 (p < 0.005). In smokers more than 40 years of age and with smoking index more than 200 (n = 184), 48 (26%) had obstruction and in smokers less than 40 years of age and smoking index less than 200 (n = 276), 15 (5.43%) had obstruction (p < 0.005). CONCLUSION: Early detection of COPD by spirometry especially in smokers more than 40 years of age and with smoking index of more than 200 is likely to reduce the overall burden of disease.

Are pulmonary opacities a marker of pulmonary tuberculosis?

BACKGROUND: On most occasions treatment of pulmonary tuberculosis is started by physicians based predominantly on radiological opacities. Since these opacities may not be suggestive of active pulmonary tuberculosis and most of these opacities may even remain unchanged after complete treatment, starting treatment solely on the basis of these opacities may lead to ambiguous end points of cure. In view of this, study of misdiagnosis of radiological opacities as active pulmonary tuberculosis by physicians was undertaken in one of the respiratory centers of Armed Forces hospitals. METHODS: This was a prospective study of patients referred to our center for confirmation of active disease and institutional therapy. All patients who were diagnosed as pulmonary tuberculosis predominantly on radiological basis by physicians were evaluated for active pulmonary tuberculosis clinically, radiologically and microbiologically. Patients found to have inactive disease were followed for one year. At three monthly review, history, clinical examination, sputum AFB and chest radiographs were done. RESULTS: There were 36 patients [all males, mean age: 36.9 years (range: 22-46 years)]. The most common initial presentation was of asymptomatic persons (33.3%) reporting for routine medical examination. The commonest radiological pattern was localized reticular opacities (52.8%)On follow up, only one patient was diagnosed to have pulmonary tuberculosis. The final diagnosis was consolidation in 6, bronchiectasis in 8, pulmonary tuberculosis in 1 and localized pulmonary fibrosis in 21 patients. CONCLUSION: Diagnosing and treating tuberculosis predominantly on radiological basis is not appropriate and sputum microscopy and culture remains the cornerstone of diagnosing pulmonary tuberculosis.

Closure of bronchopleural fistula by interventional bronchoscopy using sealants and endobronchial devices.

BACKGROUND: Bronchopleural fistula (BPF) is a communication in the form of a sinus tract between the pleural space and the bronchial tree. Chronic bronchopleural fistula (BPF) is a rare but a serious complication of several pulmonary and postoperative conditions. BPF carries a high morbidity and mortality and is associated with prolonged hospital stay and thus high resource consumption. Till date surgical intervention has been the main stay of management of chronic BPF. Our study was carried out to study the efficacy of sealants like Bioglue, Tissel glue and endobronchial devices like coils to close the BPFs through bronchoscopic interventions in those cases which failed to close with the conventional treatment regimen and progressed to chronicity. METHOD: This study was carried out in a tertiary care hospital. A total 25 patients of chronic BPF/air leaks were selected and subjected to bronchoscopic localization and subsequent intervention using sealants and coils. RESULTS: Total 25 patients with chronic BPF were treated with bronchoscopic interventions using glues, and coils.23 patients were males and 2 were females and 14 were postoperative while 11 patients were non operative. Only smaller fistulas were amenable to glues and coils while there was recurrence in patients with larger air leaks requiring surgical intervention. CONCLUSION: From this study it is concluded that non-operative bronchoscopic interventions to seal the air leaks are effective only in smaller air leaks i.e. alveolopleural fistula (APF). The larger air leaks like leaking stump and larger bronchopleural fistula have not got long lasting and encouraging results with sealants and endobronchial devices.

Role of active nitrogen molecules in progression of septic shock.

INTRODUCTION: Active nitrogen molecules are formed as a result of cell metabolism. They are essential for cell metabolism, but when produced in excess, they contribute to the pathogenesis of several disease processes. These nitrogen molecules play an important role in vascular instability of septic shock. This study was planned to detect the role of active nitrogen molecules in the progression of septic shock. MATERIALS AND METHODS: Blood samples were collected from 118 critically ill patients admitted in ICU and from 95 healthy relatives accompanying the patients. Patients were categorized into three groups: systemic inflammatory response syndrome (n = 54), sepsis (n = 35) and septic shock (n = 29). Plasma total nitrite (nitrites and nitrates), cytokines like tumour necrosis factor-α (TNF-α) and plasma lactate were measured to assess inflammatory activity and severity of septic shock. RESULTS: High plasma levels of nitrite and nitrate (No2-/No3-) were observed in critically ill patients (mean level 78.92 µmol/l in sepsis and 97.20 µmol/l in septic shock). Mean plasma TNF-α level in sepsis was 213.50 pg/ml and septic shock was 227.38 pg/ml. CONCLUSION: Plasma No2-/No3- and TNF-α levels were high in patients with sepsis and septic shock, which increased with severity of sepsis.

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men.

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Management of primary pulmonary alveolar proteinosis: A multicentric experience.

BACKGROUND: Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by alveolar accumulation of surfactant material with reduced lung function and resulting hypoxemia. It is characterized by a variable clinical course, and whole lung lavage (WLL) is the standard treatment. Herein, we report our multicentric experience of management of primary PAP. MATERIALS AND METHODS: This retrospective study included patients with PAP managed at various armed forces respiratory centers from 2009 to 2019. The diagnosis of primary PAP was based on histopathologic confirmation on transbronchial lung biopsy or open lung biopsy and absence of causes of secondary PAP. We analyzed the response to WLL in these patients as well as the safety of the procedure. RESULTS: During the above-specified period, ten patients with a diagnosis of PAP were admitted to various armed forces respiratory centers. The median age of the patients was 34.5 years (range 23-59); there were nine males (90%). The mean duration (± standard deviation) of symptoms was 10.8 (±2.70) months. For management, WLL was done for eight patients with a median volume of 23.5 L (range 18-45) per patient. All the patients showed significant symptomatic response as well as improvement in physiological parameters with no major complications. The median follow-up of all patients was 18 (range 5-44) months. CONCLUSIONS: WLL is a safe, effective therapy in an experienced setting in patients with PAP and provides long-lasting benefits.

Assessment of the Xpert assay among adult pulmonary tuberculosis suspects with and without diabetes mellitus.

SETTING: Pune and Pimpri-Chinchwad Municipal Corporation area, Maharashtra State, India.OBJECTIVE: To assess the sensitivity and specificity of the Xpert® MTB/RIF assay among adults with suspected pulmonary tuberculosis (PTB) and with or without diabetes (DM).DESIGN: As part of a prospective cohort study, we screened 2359 adults presumed to have PTB with no history of TB. All individuals underwent testing for two sputum smears, culture, Xpert, glycated haemoglobin and fasting blood sugar. We calculated sensitivity and specificity of Xpert by comparing it with TB sputum culture result as a gold standard.RESULTS: Among screened individuals, 483 (20%) were diagnosed with DM and 1153 (49%) with pre-DM; 723 (31%) had no DM. Overall sensitivity of Xpert was 96% (95%CI 95-97) and specificity was 91% (95%CI 89-93). Xpert sensitivity was significantly higher among DM group (98%) than in the 'No DM' (95%; P < 0.01) and pre-DM (96%; P < 0.05) groups. Among sputum smear-negative individuals, Xpert sensitivity was higher in the DM group than in the No DM (92% vs. 82%; P = 0.054) and pre-DM group (92% vs. 82%; P = 0.037).CONCLUSION: High sensitivity and specificity of Xpert underscores the need for its rapid scale up for the early detection of TB in settings with a high dual burden of TB and DM.

Impact of optimal asthma education programme on asthma morbidity, inhalation technique and asthma knowledge.

INTRODUCTION: Optimal asthma education (comprising of information, self monitoring, regular medical reviews and a written action plan) significantly improves asthma management. The study was undertaken to assess the impact of optimal asthma education programme on asthma morbidity, inhalation technique and asthma knowledge. STUDY DESIGN: In non-randomized prospective trial asthma morbidity, (comprising of control of symptoms, unscheduled OPD visits and limitation of physical activities), inhalation technique and asthma knowledge were assessed before and one year after implementation of optimal asthma education programme. MATERIAL AND METHODS: One hundred and seventy two patients of persistent bronchial asthma aged 12 years or more, taking daily anti-inflammatory drugs and having not attended any type of asthma education programme before were included in the present study. RESULTS: There was significant improvement in asthma morbidity with increase in the number of patients with intermittent and mild persistent asthma and significant decrease in patients with moderate and severe persistent asthma. Before optimal AEP, 30 (17.4%) patients had visited hospital thrice or more due to asthma sickness, after optimal AEP only 5 (8.6%) patients made unscheduled visits only once to hospital (p<0.05). Limitation of physical activities was present in 80 (46.51%) patients before AEP which was significantly reduced to 15 (8.7%) patients after optimal AEP (p<0.05%). Before AEP, inhalation technique was incorrect in 140 (81.3%) patients and after AEP none of the patients had incorrect technique (p<0.001). Only 24 (13.9%) patients had satisfactory knowledge of asthma before AEP and after AEP the number increased significantly to 120 (69.7%) (p<0.001). CONCLUSION: Optimal asthma education is an integral part of asthma management which decreases asthma related morbidity, improves inhalation technique and asthma knowledge. Since our follow up was for one year and impact of asthma education programme is likely to decrease in absence of regular follow up, it is important to keep reminding patients about asthma education programme at each follow up visit.

Cough of more than two weeks - Time to think beyond pulmonary TB.

BACKGROUND: Cough of more than two weeks has become sine quo non with pulmonary tuberculosis (PTB) in a developing country like India. The causes may be different in patients reporting to respiratory OPD vis a vis general OPD. AIMS AND OBJECTIVES: To study the prevalence of PTB and causes of cough other than PTB among respiratory OPD attendees with cough of more than two weeks duration. METHODS: A cross sectional study was carried out over two years in respiratory OPD of a tertiary care chest center of Indian armed forces. Of the 13,004 patients, 505 non HIV PTB suspects were included. Patients with definitive diagnosis of chronic cough were excluded. Efforts were made to establish diagnosis of pulmonary TB using clinical, microbiological and radiological features. However, patients were also subjected to further evaluation (spirometry, bronchoscopy, CECT) based on clinical features, radiological and lab profile to establish definitive diagnosis. RESULTS: Out of the 505 patients, 10.5% patients had smear positive pulmonary TB, 13.5% smear negative PTB, bronchial asthma (24%), COPD (9.3%), diffuse parenchymal lung diseases (DPLD's) (12.5%), bronchiectasis (6.3%), lung cancer (5.3%) and congestive cardiac failure (4.2%). CONCLUSION: Though prevalence of PTB in the study correlated well with the national statistics, but a significant number of patients had other causes of chronic cough, especially, obstructive airway diseases and DPLDs. Thus, there is a need to spread awareness regarding other causes of chronic cough and all efforts should be made to establish alternate diagnosis especially in patients who do not conclusively have PTB.

Intrapleural fibrinolytic therapy in complicated parapneumonic effusion and empyema: present status.

Pneumonia remains one of the commonest community- and hospital-acquired infection despite the advent of potent antimicrobial agents. A significant number of patients with pneumonia develop parapneumonic effusions. The parapneumonic effusion may be "simple" consisting of free-flowing, clear exudative fluid which almost resolves completely with antibiotics alone. In case of delayed or inappropriate treatment, some of these simple effusions progress to complicated parapneumonic effusions and empyema. The management of these types of effusions with intercostal tube drainage and antibiotics fails most of the time due to the presence of thick viscous fluid and multiple pleural space loculations. The various therapeutic options available at this stage include intrapleural instillation of fibrinolytic agents, breaking down of loculations or decortication either by video-assisted thoracosopic surgery (VATS) or thoracotomy and open drainage procedures. Video-assisted thoracic surgery is a better option but it is neither easily available nor affordable by majority of patients in developing countries, like India. Intrapleural instillation of fibrinolytic agents has been found to be a useful adjunctive therapy in various small uncontrolled and randomised trials. After a recent and first large multicentre trial which showed that this therapy does not have any significant effect in reducing mortality and need for surgery in patients with pleural infection, the role of intrapleural fibrinolytics has become more controversial. In view of this, there is a need to re-define its role especially in the developing countries.

Trends in HbA1c levels and implications for diabetes screening in tuberculosis cases undergoing treatment in India.

SETTING: The optimal timing of screening for diabetes mellitus (DM) among tuberculosis (TB) cases is unclear due to the possibility of stress hyperglycemia. DESIGN: We evaluated adult (18 years) pulmonary TB cases at treatment initiation as well as at 3 months, 6 months and 12 months. DM was identified by self-report (known DM) or glycated hemoglobin (HbA1c)  6.5% (new DM). Trends in HbA1c levels during treatment were assessed using non-parametric tests. RESULTS: Of the 392 participants enrolled, 75 (19%) had DM, 30 (40%) of whom had new DM. Of the 45 participants with known DM, respectively 37 (82%) and 40 (89%) received medication to lower glucose levels at treatment initiation and completion; one participant with new DM initiated glucose-lowering medication during follow-up. The median HbA1c level in participants with known, new and no DM was respectively 10.1% (interquartile range [IQR] 8.3-11.6), 8.5% (IQR 6.7-11.5) and 5.6% (IQR 5.3-5.9) at treatment initiation, and 8.7% (IQR 6.8-11.3), 7.1% (IQR 5.8-9.5) and 5.3% (IQR 5.1-5.6) at treatment completion (P < 0.001). Overall, 5 (12%) with known and 13 (43%) with new DM at treatment initiation had reverted to HbA1c < 6.5% by treatment completion (P = 0.003); the majority of reversions occurred during the first 3 months, with no significant reversions beyond 6 months. CONCLUSION: HbA1c levels declined with anti-tuberculosis treatment. Repeat HbA1c testing at treatment completion could reduce the risk of misdiagnosis of DM.