Enndobronchial Ultrasound-guided trans-Bronchial needle aspiration for the diagnosis of Granulomatous versus non Granulomatous lung diseases

Objective: To evaluate the diagnostic accuracy of Endo-bronchial ultrasound guided transbronchial needle Aspiration in patients with mediastinal lymphadenopathy and mass lesions especially in the context of granulomatous versus non granulomatous lung disorders

Study Design: Open label, unblended prospective observational cohort

Place and Duration of Study: Department of Pulmonology, Pak Emirates Military Hospital Rawalpindi, from July 2015 to Mar 2016

Patients and Methods: All patients presented during study periods with meditational lymphadenopathy or lesions in which the initial bronchoscopy did not reveal any diagnosis were included in the study. Endobronchial ultrasound-guided transbronchial needle aspiration was performed in the bronchoscopy suit under conscious sedation and local anesthesia. Rapid on site evaluation was available for most of the cases. The procedure was performed using an integrated fibreoptic bronchoscopy with 22G TBNA needle by an experienced Bronchoscopist. The data was analyzed by using SPSS version 21

Results: A total of 53 patients with mean age of 44 years underwent endobronchial ultrasound-guided transbronchial needle aspiration for evaluation of meditational or hilar lesions between Jul 2015 to Apr 2016. There were 43 [81.1percent] male and 10 [18.8percent] female patients. A total of 108 Lymph nodes were sampled in 53 patients, rapid on site evaluation was available in 41 [77.3percent] patients. Adequate representative sample could be obtained in 45 of 53 [84.9percent] patients. The overall diagnosis were chronic granulomatous lesion in 27 [50.9percent] patients, squamous cell carcinoma in 10 [18.8percent], lymphoproliferative disorder in 2 [3.7percent], thymoma in 1 [1.3percent] and reactive hyperplasia in 5 [9.4percent] of cases. No major complication of the procedure was observed

Conclusion: End bronchial ultrasound-guided transbronchial needle aspiration was found useful diagnostic modality for lymph nodes sampling in patients with lymphadenopathy and mass like lesions in mediastinum

Percutaneous tracheostomy by physician intensivists

Objective: To assess the safety of percutaneous tracheostomy when performed by physician intensivists

Study Design: Descriptive study

Place and Duration of Study: Adult Medical ICU in the Department of Critical Care Medicine, Military Hospital, Rawalpindi, Pakistan, from September 2013 to August 2016

Methodology: Departmental record for percutaneous tracheostomies, performed by physician intensivifts, was evaluated. Variables studied were underlying primary diagnosis, details of the operating doctors, presence of immediate complications, departmental protocol for the procedure, pre-procedure safety checklist, written instructions on procedure steps, use of ultrasound and bronchoscopy. Portex Percutaneous Dilation Tracheostomy Kit with Single-Stage Dilator was used in all the patients

Results: Fifty-six percutaneous tracheostomy procedures were performed with a male to female ratio 3:1; more than 2/3[rd] [80%] had an underlying neurological illness. All doctors performing the procedures were physicians having minimum qualification of Fellowship with at least one year experience in intensive care and had observed at least five procedures. Departmental protocol for the procedure was followed in all the cases. Minor complications were observed in three patients [5.35%]. These included para-tracheal misplacement, accidental de-cannulation, and endotracheal tube cuff puncture. None of the patient died due to direct complications of the procedure

Conclusion: Percutaneous tracheostomy is safe in Medical ICUs of developing countries, when performed by experienced physician intensivists under defined protocols

Electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults

Objective: To determine the efficacy and safety of electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults. Study Design: Open label, unblinded series. Place and Duration of Study: This study was carried out at the Department of Neurology, Military Hospital Rawalpindi, from Jan 2015 to Dec 2015

Material and Methods: All the patients with the diagnosis of NMS during the study period were included in the study. Consective non-probability sampling technique was used. Patients were divided into two groups; uncomplicated and complicated cases of NMS

Results: A total of nineteen patients were included in this pilot study. Out of all, thirteen [68.4%] were males and six [31.6%] were females. Mean age of the patients was 35.05 [SD 13.362] years. The drug classes causing NMS were antipsychotic medicines in 73.7% of patients and antiemetics in 26.3% of patients. Mean electroconvulsive therapy [ECT] sessions given were 6.16 [SD 2.062]. Following treatment n=16 [84.2%] patients had complete recovery while n=3 [15.3%] patients died

Conclusion: In this small, open label, unblinded study ECT appears effective and safe in treating NMS in adults. Larger randomized studies will help to confirm data emerging from this preliminary study

Sputum neutrophilia in severe persistent asthmatics

Objective: To determine the frequency of sputum neutrophilia in patients with severe persistent bronchial asthma. Study Design: A cross-sectional study. Place and Duration of Study: Department of Medicine, Military Hospital, Rawalpindi, from November 2009 to November 2010

Methodology: Cases of severe persistent bronchial asthma, aged between 12 and 40 years, were included. Sputum samples were collected by induction with hypertonic saline [4.5%]. All samples were centrifuged and differential neutrophil count was calculated. Data was analyzed using SPSS 11

Results: Out of 195 patients, there were 129 [66.2%] males and 66 [33.8%] females. The mean age was 27.01 +/- 6.92 years. Mean sputum neutrophilic count was 126.47 +/- 16.52 x 106/ml and the mean neutrophilic percentage was 63.187 +/- 8.3363. Sputum neutrophilia was present in 84 patients [43.1%], out of whom, 56 were males and 28 females. In patients with sputum neutrophilia, mean neutrophilic count was 142.40 +/- 8.49 x 106/ml and the mean neutrophilic percentage was 71.2024 +/- 4.2441%

Conclusion: Sputum neutrophilia is a frequent finding in cases with severe persistent bronchial asthma. Presence of sputum neutrophilia in such cases can lessen the inappropriate use of corticosteroids with their associated long-term side effects

clinical account of hospitalized 2009 pandemic influenza A [H1N1] cases

To determine the clinical characteristics in adults with confirmed pandemic influenza A [H1N1] infection 2009. A case series. The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010. Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction [RT-PCR] were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form. Mean age was 34.24 +/- 13.92 years with 61.1% females. Seventeen [47.2%] had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever [97.2%], cough [97.2%], rhinnorhea [80.6%], and shortness of breath [58.3%] were the commonest symptoms. Radiographic abnormalities were interstial/reticular infiltrates [30.6%], patchy consolidations [11.1%] and reticular shadows with areas of consolidation [25%]. PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase [CK] levels greater than 400 U/L and lactate dehydrogenase [LDH] levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay. The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A [H1N1] is vital to prevent the rapid disease progression

clinical account of ICU cases with severe H1N1 [2009 pandemic influenza A] infection

To determine clinical characteristics in adults with confirmed severe 2009 pandemic influenza A [H1N1] infection. A descriptive case series. The study was carried out at the department of Pulmonology and Critical Care, Military Hospital Rawalpindi, from 1st December 2009 to 30th May 2010. Fifteen in-hospital adults with severe H1N1 infection confirmed by reverse transciptase polymerase chain reaction [RT-PCR] were studied. A pre-designed patient data collection form was used to record clinical features, laboratory and radiological investigations and management data. Mean age for severe H1N1 cases was 41.56 +/- 15.08 years and about 75% cases were from 20-40 yrs age group. Seventy five percent of our cases had at least one risk factor for complications with 2009 H1N1 infection; namely obesity - 33.3%, smokers - 26.7%, pregnancy, COAD and diabetes mellitus - 20% each. Fever [100%], cough [100%], and shortness of breath [93.3%] were the commonest symptoms. Radiographic abnormalities were bilateral patchy consolidations [60%], interstitial/ reticular infiltrates [20%], and reticular shadows with areas of consolidation [20%]. PaO[2]/ FiO[2] ratio was less than 200 in 60% cases on presentation. 73.3% cases had 1000-2000 [U/L] lactate dehydrogenase [LDH] levels while creatinine kinase [CK] levels were 400-1000 [U/L] in 66.7% cases. Six [40%] ICU cases with severe H1N1 infection died during hospital stay. Severe H1N1 virus infection cases most commonly presented with fever, cough and shortness of breath. The severe H1N1 cases presenting with abnormal chest radiograph and hypoxemia require ICR care with high mortality

Diacetylmorphine [heroin] body packer presenting with respiratory arrest

Intracorporeal concealment of illicit drugs known as 'body packing' is uncommonly reported. A body packer with swallowed capsules containing Diacetylmorphine [heroin] for smuggling purposes presented with respiratory arrest and recovered after ventilatory support and nalaxone infusion

Comparison of diagnostic yield of AFB with sputum induction to spontaneous sputum examination in suspected pulmonary tuberculosis

To compare the diagnostic yield of AFB positivity with sputum induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis. Comparative study. Military Hospital, Rawalpindi, from January to December 2006. Sputum specimens were collected by both techniques from 164 patients with clinical and radiological suspicion of pulmonary tuberculosis admitted in medical wards. All specimens were examined for AFB smear and culture positivity. Sputum induction was done for 15-20 minutes with 3% sterile hypertonic saline solution by nebulization in all cases. Proportions were compared using Chi-square test. Among 164 patients, 32 patients [19.5%] were not expectorating spontaneously. Sputum induction was successful in 22 [68.75%] cases and AFB smear was positive in 03 [9.37%] and AFB culture was positive in 7 [21.8%] of these cases. One hundred and thirty two [80.5%] patients were already expectorating and both Day-1 [spontaneous] and Day-2 [induced] sputum samples were available. Day-1 [spontaneous] sputum specimens revealed AFB smear positive results in 20 [15.15%] patients, and AFB culture positive results in 24 [18.18%] patients. Smear positivity on Day-2 [induced] sputum samples was 21.21% [28] with 27.27% [36] culture positivity. In expectorating patients, AFB smear and culture positivity results remain comparable with spontaneous and induced sputum sampling. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample

Montelukast as add-on therapy to inhaled beclomethasone in persistent bronchial asthma

To evaluate the efficacy of Montelukast as add-on therapy in moderate persistent asthma with inadequate control on high dose inhaled beclomethasone. A quasi experimental study. The study is carried out at the Combined Military Hospital Multan, from 1st Nov 2006 to 30th May 2007. One hundred nonsmoking symptomatic asthmatics with one year history of moderate persistent bronchial asthma being treated with high dose inhaled beclomethasone dipropionate for at least 6 weeks before the study were selected as per inclusion criteria. Group-I [47 cases] was given inhaled beclomethasone [1000 µg daily in two divided doses] alone for 12 weeks. While Group-II [48 cases] received both inhaled beclomethasone [1000ug daily in two divided doses] and Montelukast Sodium 10 mg at bed time for 12 weeks. Seven-point global evaluation score and Pulmonary function test [PFTs] were done at 0, 6 and 12 weeks; and the need for use of rescue 2-agonist was also calculated in both groups. Mean age of patients was 29.30 years [SD +/- 7.04] with 64.22% males. There was significant difference in episodes of dyspnea and wheeze among group I and group II at 6 weeks while all four parameters including cough and nocturnal awakenings were significantly less at 12 weeks in group II. Similar comparative improvement in mean FEV1 was seen at 12 weeks in group II. Combined therapy also reduced the use of rescue inhaled 2-agonist treatment. Montelukast sodium as add-on therapy to high dose inhaled beclomethasone provides significant complementary clinical benefits in symptomatic moderate persistent asthmatics

Diagnostic yield of transbronchial needle aspiration analysis of 30 cases

In our clinical set up transbonchial needle aspiration of lymph node and parenchymal lesions is an underutilized technique. This study was done to highlight the usefulness of this technique in the pulmonologists armamentarium. Thirty procedures were performed on patients with intrathoracic lymphadenopathy or parenchymal lung lesions in this study from October, 2006 to April, 2007. Patients with an easily accessible peripheral lymph node, bleeding diathesis and an already confirmed diagnosis were excluded from the study as were patients with a well visualized biopsiable endobronchial lesion. Nineteen patients [63.3%] on whom transbonchial needle aspirations were performed had intrathoracic lymphadenopathy while 11 [36.6%] had parenchymal lesions without endobronchial lesions which could be biopsied. Adequate samples were obtained in 23 patients [76.6%] chronic granulomatous inflammations which was diagnosed as tuberculosis in corroboration with other clinical and laboratory evidence was seen in 3 cases [10%]. Carcinoma was diagnosed in 6 cases [20%]. Thirteen cases [43%] were reported as normal and inadequate samples were obtained in 7 cases [23%]. Transbronchial Needle Aspiration [TBNA] is an effective method of obtaining cytological material from intrathoracic lymph nodes and parenchymal lesions and can provide a safe alternative to invasive mediastinotomy/mediastinoscopy and open lung biopsya

High resolution computed tomographic patterns in adults with pulmonary tuberculosis

To determine the High Resolution Computed Tomographic [HRCT] patterns in adults with Acid Fast Bacillus [AFB] positive new cases of Pulmonary Tuberculosis [PTB]. The study was carried out at the Department of Pulmonology and Department of Radiology, Military Hospital, Rawalpindi, from June 2006 to August 2007. Fifty adults with AFB positive new pulmonary tuberculosis were included in the study, while PTB cases in the retreatment category, Multi Drug Resistant [MDR] tuberculosis, PTB with Chronic Obstructive Airways Disease [COPD], pneumoconiosis, Diffuse Parenchymal Lung Diseases [DPLDs] etc. were excluded. All cases underwent HRCT chest with 2 mm collimations at 10 mm intervals. Relevant data was collected on a pre-designed patient proforma. The mean age was 40.18 +/- 14.55 years with 88% males; 46% and 30% samples were sputum and endobronchial washings smear positive for AFB respectively, while the rest were culture positive. HRCT findings included centrilobular nodules in 92% cases, lobular consolidation in 84%, cavitation in 76%, 'tree-in-bud' appearance in 68%, lymphadenopathy in 8% and miliary nodules in 4% cases. HRCT patterns included centrilobular nodules and lobular consolidation in 80% cases, while centrilobular nodules with cavitation and centrilobular nodules with 'tree-in-bud' appearance were noted in 72% and 68% patients respectively. Thirty two [64%] cases had centrilobular nodules, cavitation and lobular consolidations and about half cases had centrilobular nodules, 'tree-in-bud' appearance and lobular consolidation. Centrilobular nodules and lobular consolidations [80%], centrilobular nodules with cavitation [72%] and centrilobular nodules with 'tree-in-bud' appearance [68%] were the most common HRCT patterns in adults newly diagnosed with pulmonary tuberculosis

Right ventricular myxoma with heart failure

Cardiac myxomas are histologically benign tumors but they may be lethal because of their strategic position. These are mostly located in the left atrium and uncommonly in the right atrium. We report a case of a large right ventricular myxoma presenting with heart failure

Small cell lung cancer chemotheryapy: a nine year experience of, London lung cancer group protocol

Lung cancer is the leading cause of cancer related deaths. Small cell lung cancer is found in 20-25% cases. Chemotherapy is cornerstone of treatment. With appropriate therapy majority of patients with small cell lung cancer can expect to achieve remission and a significant prolongation of life. Our objective was to evaluate the 'London Lung Cancer Group Protocol' for chemotherapy of Small Cell Lung Carcinoma being followed in our unit. This hospital based prospective study was carried out in Pulmonology Department of Military hospital, Rawalpindi between May 1989 to May 1998. In total 484 cases of bronchogenic carcinoma were diagnosed. Sixty eight had small cell cancer while 416 had non small cell lung cancer. 39 patients who fulfilled the inclusion criteria were subjected to thorough clinical examination and detailed investigations to ascertain the stage of the disease. The patients were then divided into groups according to the staging. Fifteen patients [38.4%] with limited disease were in Group I, while 24 patients [61.5%] with extensive stage disease and good prognosis were in Group II. Most patients [43.5%] were between age 51-60 years, [38.4%] 61-65 years of age, [12.8%] were 41-50 years and only 5.1% patients were between 31-48 years. Commonest presenting symptom [92.3%] was cough, while 58.9% had hemoptysis, 48.7% severe dyspnoea, 20.5% superior venacaval obstruction and 38.4% chest pain. The most common side effect of chemotherapy was alopecia [61.5%] followed by GI symptoms other than vomiting [30.7%]. One patient had cardiac decompensation and two had myelosupression. In total 30 cases [76.9%] completed chemotherapy. Treatment was abandoned in five cases [12.8%] due to various reasons while 4 were lost to follow up. Out of the 30 patients who completed chemotherapy 60% were complete responders while 40% were partial responders. Symptoms regressed considerably after treatment. Median survival was fifteen months in group I and nine months in group II. We concluded that 'London Lung Cancer Group Protocol being followed at our unit had good response rate, was safe and cost effective and had minimal side effects

Endobronchial tuberculosis: clinical and diagnostic aspects

This study was conducted at the Department of Pulmonology, Military Hospital Rawalpindi from Jan 1990 to Dec 2000 to determine common clinical features and diagnostic aspects especially bronchoscopic characteristics of endobronchial tuberculosis. A total of 180 consecutive cases of Endobronchial Tuberculosis of all ages and both sexes were included. The mean age was 29.82 ['4.32] years. Male to Female ratio was 2.4:1. Cough was the most common symptom [90.59%] with expectoration in 50.55% patients. Fever and hemoptysis were noted in 83 and 67 cases respectively. History of weight loss was present in 20.55% patients while chest pain and exertional dyspnea were noted in 17.77% and 13.33% cases respectively. Chest X-rays were normal in 77.77% cases. Endobronchial lesions on bronchoscopy were noted in upper lobes in 59.74% cases while lower lobe lesions were seen in 40 [25.97%] cases and 22 [14.28%] patients had involvement of right middle lobe or major bronchi. Endobronchial secretions yield for AFB positivity was cent% and commonest histopathological feature was non caseating granuloma. Endobronchial tuberculosis is not an uncommon entity but due to non specific symptomatology and normal chest X-ray, a high index of clinical suspicion is required for timely diagnosis and appropriate management. Fiberoptic bronchoscopy with biopsy and bronchial washings is the investigation of choice