Randomized controlled trial to study efficacy of 1% versus 2% lignocaine in topical airway anaesthesia in routine bronchoscopy procedures
Danny Prasad, Prince James, Richa Gupta
Department of Respiratory Medicine, CMC, Vellore, Tamil Nadu, India. E-mail: dannyprasad29@gmail.com
Background: The optimal concentration of lignocaine to be used during flexible bronchoscopy is unknown. This randomized controlled trial compared the efficacy of 1% and 2% lignocaine solution for topical anaesthesia during routine procedures in flexible bronchoscopy.
Methods: Consecutive patients were randomized to receive either 1% or 2% lignocaine. All patients received a minimum sedation of 2mg Midazolam and 25 mcg Fentanyl sodium. The primary outcome of the study was the assessment of cough by the operator, sister assisting and the respiratory therapist assisting and the patient using the visual analogue score (VAS). The key secondary outcomes looked into was the total lignocaine dose, overall satisfaction of procedure as assessed by bronchoscopist and pain felt by patient (VAS) score.
Results: Five hundred patients were randomized (median age, 46 years; 65.4% men) 1:1 to either group. The mean cough VAS score as assessed by all the concerned parties in both groups were similar. Th pain rating was similar between the two groups. The mean total dose of lignocaine was similar in both groups (24.5 ml vs 25.3 ml). When converting the equivalent dosing in milligram the 2% lignocaine is twice as compared to 1% lignocaine arm (49 mg vs 50.6 mg). There was no adverse event related to lignocaine overdose was seen in either group.
Conclusions: 1% lignocaine was found to be as effective as 2% solution for topical anaesthesia during routine flexible bronchoscopy procedures, and at a significantly lower dose as the latter. Th us, 1% lignocaine should be the preferred concentration for topical anaesthesia.
Post COVID pulmonary complications: spontaneous pneumothorax; Pneumomediastinum: A retrospective study
Varsha Raj Meena, Suman Khangarot, Anil Saxena
G.M.C., Kota, Rajasthan, India. E-mail: varshajipatan@gmail.com
Background: Coronavirus disease 2019 (COVID-19) is a communicable disease caused by SARS-CoV-2. Ranging from atypical pneumonia to respiratory failure & ARDS. The complications are pulm fibrosis, pneumothorax /pneumomediastinum, pleural effusion & TB. Development of a pneumothorax is emerging complications. potential cause is structural changes include cystic & fibrotic changes leading to alveolar tears. Also Increase in intrathoracic pressure from prolonged coughing or respiratory support. However, pneumothorax was rare complication all patients required placement of chest tube. The reactivation of tb due to decreased in built immunity or due to steroids.
Materials and Methods: We performed a retrospective review. Cases were collected from Govt medical college Kota. Clinical, radiological, demographic and laboratory data were collected. Also Diagnosed with pulm complications.
Results: 50 cases were included. Study done btw November 2020 to August 2021. 34 patients covid RT PCR positive, 16 patients were negative (positive in CT). 40 patients were hospitalized, 10 were home isolated during covid infection. Hydropneumo/pneumothorax develop in 12 (24%), with associated pneumomediastinum in 3 (6%) patients, primary tb or reactivation tb in 8 (16%), pleural effusion 1 (2%) patient. post covid fibrosis was found in most of cases 41 (82%).
Conclusion: COVID 19 affect the whole body, the post covid fibrosis is main complications. both pneumothorax or pneumomediastinum may be present during or after SARS COVID 19 pneumonia even in non-intubated patients.
Co-relation between computed tomography-chest and Inflammatory markers in COVID-19 patients in a tertiary care hospital in central India
Pushpak Goyal, Ratan Kumar
Department of Pulmonary Medicine, LNMC and J.K. Hospital, Bhopal, Madhya Pradesh, India. E-mail: pushpak.goyal2011@gmail.com
Background: In December of 2019 a new corona virus was identified by WHO, secondary to an unfamiliar pneumonia in Wuhan, China, which was initially named 2019 Novel Corona Virus (2019-nCoV), and later named Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2). Diagnosis was made on the basis of RT-PCR test.
Methods: With use of RT-PCR as the reference standard, the performance of chest CT in the diagnosis of COVID-19 was assessed. Findings of the investigations such as HRCT, D-dimer, Sr. Ferritin, CRP, and LDH are recorded and analysed.
Results: Total patients included in the study are 217 persons of which 57.89% are males, 42.10% are females. The mean age was 45.14-years. CT severity score was found to be positively correlated with increased D-dimer, LDH and S. ferritin levels. It was found that with increasing HRCT chest severity, there was increase in inflammatory marker parameters.
Conclusion: Our data suggest the potential role of D-dimer, S. Ferritin and LDH for predicting severity of disease and CT scan. CT score is highly correlated to laboratory findings and might be beneficial to speed up diagnostic workup in symptomatic patients and also play a vital role in predicting the severity in places where HRCT scan is not available.
Development of a COPD screening tool: The OSCAR study
Deesha Deepak Ghorpade1,2,3, Jyoti Deepak Londhe1, Sapna Jitendra Madas1,2, Anchala Raghupathy1, Nisha Vijay Kale1, Narula Arvinder Pal Singh4, Reshma Sudhir Patil4, Prakash Prabhakar Rao Doke4, Sundeep Santosh Salvi1,2,3
1Chest Research Foundation, Pune, Maharashtra, India, 2Pulmocare Research and Education Foundation, Pune, Maharashtra, India, 3Savitribai Phule Pune University, Pune, Maharashtra, India, 4Bharti Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India. E-mail: deesha@purefoundation.in
Background: COPD remains underdiagnosed in India, which can be overcome by developing a simple COPD screening tool (Questionnaire +/- peak flow meter) that can be used by community health workers (CHWs). We aimed to develop a COPD screening tool for the CHWs.
Methods: 5420 male and female subjects above the age of 30 years were randomly selected from 11 urban slums and 7 rural villages from Pune district. They were administered a questionnaire containing 129 variables developed through literature review, in-depth interviews with COPD patients and focused group discussion with pulmonologists. Pre and post bronchodilator spirometry along with peak flow metry were also performed. Using post-bronchodilator FEV1/FVC < 0.7 as the gold standard for COPD, we reduced the 129 variables using chi square test and random forest filters to the lowest number of variables along with a PEFR value and derived a cut-off score that had maximum sensitivity (SN), specificity (SP), positive predicted value (PPV) and negative predicted value (NPV).
Results: Clean data was obtained from 4258 participants. 8 candidate items i.e., age, gender, smoking status, shortness of breath, cough, wheezing, chest tightness and long-standing history of asthma in addition to a peak flow meter (<250L/min for males and <200 L/min for females), yielded a SN, SP, PPV and NPV of 51.6%, 97.5%, 52.4% and 97.4% respectively with an overall accuracy of 95.2%, for a cut-off value of ≥ 8 (maximum 14).
Conclusion: We have developed the OSCAR tool for COPD screening in the community that can be widely used by CHWs.
A novel pncA gene deletion conferring pyrazinamide resistance in Mycobacterium tuberculosis
Amrutraj Zade1, Sanchi Shah1, Chaitali Nikam2, Anirvan Chatterjee1
1Haystack Analytics, SINE, Indian Institute of Technology Bombay, Mumbai, Maharashtra, India, 2Thyrocare Laboratories, Mumbai, Maharashtra, India. E-mail: anirvan@haystackanalytics.in
Background: For decades, TB remains a major communicable disease of global concern, with multidrug resistance, deteriorating the situation. pncA gene deletion can confer resistance to pyrazinamide, lengthening the treatment regimen and detecting this might be challenging by conventional drug-sensitivity tests.
Case Study: An individual complaining of cough, fever, and breathlessness for a few months, reported at the district TB center, Khammam, India. Whole Genome Sequencing (WGS), detected resistance towards isoniazid, rifampicin, streptomycin, ethambutol. Further analysis confirmed a novel pncA gene deletion of 1875 bp (covering partly rv2044c to whole pncA, rv2042c, and partly rv2041c), causing pyrazinamide resistance.
Discussion: Mutation in pncA gene can majorly cause pyrazinamide resistance,with mutation hot-spots distributed along pncA gene. Moreover, complete deletion of pncA gene resulting in the pyrazinamide resistance is a rare event and not many cases have been reported. pncA has the highest frequency of convergent indels, exhibiting high levels of homoplasy, suggesting independent acquisition of the mutations or deletion. In this study, along with multi-gene deletion, we observed complete pncA deletion. This possibly instigated pyrazinamide resistance, due to selection pressure caused by re-treatment of MDR/TB patient previously treated with a first-line antimicrobial drug containing pyrazinamide.
Conclusion: WGS successfully detected a novel pncA gene deletion of 1875 bp, probably causing pyrazinamide resistance and influencing other drugs. WGS is a rapid and now-affordable technique that plays a crucial role in detecting antimicrobial resistance and increases the sensitivity of detection.
Post COVID 19 autoimmune complications: Two cases
Priya Sharma, Rajesh Yadav, Vatsal Bhushan Gupta, Saurabh Karmakar
All India Institute of Medical Sciences, Patna, Bihar, India. E-mail: priyasharma26292@gmail.com
Background: Autoimmune disease in adults, among spectrum of complications of COVID 19 is rare.
Case Study: Both the cases were never smokers and had type 2 diabetes mellitus, hypertension and hypothyroidism with history of severe COVID 19 eleven months back in case I and seven months back in case II. Case I is 36 year old female, had off and on cough and fever (with spikes of 102o F) for one month along with loss of appetite and weight. CECT thorax showed multifocal GGOs and nodules and CT guided biopsy showed epitheliod granulomas. Fever had not responded to course of ATT. Monteux test showed no induration and BAL was negative for CBNAAT, fungal smear and culture and malignant cytology for both patients. PET CT showed metabolically active bilateral lung nodules. NCCT PNS was suggestive of pansinusitis. cANCA was positive. Case II is a 63 year male, had off and on dry cough and dyspnea off and on (grade 2 mMRC) for 2 months associated with loss of appetite and weight. Hb was 6 gm/ dl and indirect Coombs test was positive. USG whole abdomen showed coarse echotexture with multiple small nodular hypoechoic lesions in liver and spleen and splenomegaly. Serum ACE level was 95 mcg/ L. CECT thorax showed discrete areas of consolidation and ground glass opacity with perifissural and peribronchovascular nodules. TBLB showed non necrotizing granulomatous inflammation. Diagnosis of post COVID ANCA associated vasculitis was made in case I and post COVID sarcoidosis in case II. Both patients responded to immunosuppression.
Discussion: Literature shows evidence for similar pathogenesis and clinical-radiological aspects between the hyper-inflammatory diseases and Covid-19 which might explain SARS-CoV-2 for the development of a rapid autoimmune and/or autoinflammatory dysregulation. Host-pathogen interactions at different points of the viral life cycle seem to be important for explaining in part the heterogeneity of clinical pictures that characterize COVID-19.
Conclusion: In this progressively increasing global COVID-19 pandemic, it remains necessary to investigate early to find the effects and interactions of various immunological and autoimmune diseases in patients with recent history of COVID-19 and further intervene.
Non-invasive ventilation in acute hypoxemic respiratory failure patients: changes in pao2/fio2 ratio and SpO2/fio2 ratio as a predictor of non-invasive ventilation success
M. Sathish Kumar, A. Mahilmaran, A. Sundararajaperumal, D. Nancy Glory, G. Allwyn Vijay
Institute of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: sathishkumar.m1994@gmail.com
Background: Non-invasive ventilation (NIV) is a method that can be used in acute respiratory failure patients. NIV may improve outcome by avoiding intubation, but may worsen outcome by delaying intubation in those having failed NIV. Therefore, factors predicting the success rate of NIV will be useful for early intervention and management.
Objective: To study the variables predicting the success rate NIV in AHRF patients.
Methods: 331 patients with Acute Hypoxemic Respiratory Failure (AHRF) who were initiated on NIV were enrolled in our study. Variables like PaO2/FiO2 ratio, SPO2/FiO2 ratio were analysed for predicting the outcome of NIPPV in AHRF patients.
Results: NIV success vs failure patients, the mean baseline PaO2/FiO2 ratio (PFR) (mean±SD-146.6±34.2 vs 179.6±16.3; p value <0.01) and PFR 1 hour after initiation of NIV (189.3±36.1 vs 160.5±32.3; p value <0.01) were comparable. The NIV success group demonstrated a progressive improvement in PFR in comparison with the failure group at 1 hour, 6 hours, 12 hours. NIV success vs failure patients, the mean SPO2/ FiO2 ratio (SFR) (191.6±49.4 vs 135.5±42.8; p value <0.01) and SFR 1 hour after initiation of NIV (219.9±69.1 vs 153±43.6; p value <0.01) were comparable. PFR at 1 hour <174 and SFR at 1 hour <179 were associated with increased risk of NIV failure.
Conclusion: PFR and SFR can be used to predict the outcome of NIV in AHRF patients. SpO2/ FiO2 ratio is found to be simple non-invasive bedside predictor for the outcome of NIV in AHRF patients.
Predictors of mortality in COVID-19: A single center retrospective study
Kolla Madhuri, Amrut Kumar Mohapatra, C. M. Rao, Suman Kumar Jagaty
Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: kollamadhuri94@gmail.com
Background: The second wave of the COVID-19 pandemic created a havoc everywhere, especially in developing countries. There was a dearth of hospital beds, oxygen supply and healthcare personnel. The overpopulation and improper implementation of containment strategies led to prevalence of a no. of mutated strains in India; B.1.351, B.1.1.7, Brazilian strain P.1 and double mutant strain B.1.617 to name a few. These strains were responsible for high morbidity and mortality especially in young individuals.
Aims and Objectives: In this study, we tried to determine the various factors associated with mortality in COVID-19 patients in a tertiary care COVID hospital during the second wave of the pandemic.
Results: The hospital recorded a total of 555 deaths with a male to female ratio of 2.05:1. The mean age of these patients was 57.41±15.19 yrs. The mean duration of hospital stay was 8.39±7 days. Diabetes mellitus and hypertension were the commonest co-morbidities reported in 142 (25.6%) and 106 (19.1%) cases respectively. Inflammatory parameters were markedly raised in these patients; the mean CRP was 189.58±117.64 mg/ml while the mean d-dimer was4.7965±3.5969 ng/ml. There was a significant correlation when comparing the lymphocyte count between patients with and without co-morbidities (p=0.000). The mean neutrophil to leukocyte ratio (NLR) was 19.26± 13.93.
Conclusion: The second wave of COVID-19 has affected people with a comparatively lower age. The inflammatory markers still play an important role in depicting the severity and outcome of the disease.