Executive Summary of the Recommendations on the Management of Asthma In Primary Care (2022) – New Updates

Background : Asthma is a heterogenous disease defined by the history of respiratory symptoms (shortness of breath, wheezing, cough, and chest tightness) that vary over time and in intensity, along with variable expiratory airflow limitation. Despite an ever-increasing prevalence of asthma across all age groups, this condition remains poorly managed in India. Majority of the Indian patients remain undiagnosed or wrongly diagnosed in general clinical practice and even those who get diagnosed, remain poorly or inadequately treated1,2. Since the last published 2020 Indian Medical Association (IMA) recommendations on the management of asthma in primary care, noteworthy critical changes have been recommended in relation to the diagnosis/management of asthma in international guidelines. Hence, there was a need to update the existing IMA recommendations. For the same, an expert group meeting was organized with family physicians having clinical experience in managing patients with asthma along with chest physicians and pediatricians. Important updates related to asthma diagnosis and its management were discussed and the final recommendation decisions were derived from the joint group discussion. Some of the key points derived from the discussion are mentioned below in the executive summary. For a detailed version of the new recommendations please click on the url.

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.

Massive haemothorax: a presentation of pulmonary arteriovenous malformation.

Arteriovenous malformations of the lung are relatively uncommon lesions with varied clinical presentation. Nearly half of these are associated with Osler-Rendu-Weber disease. Magnetic resonance angiography is an accurate and non-invasive diagnostic modality. We report a case of a 56-year-old male who had massive haemothorax due to rupture of a pulmonary arteriovenous malformation arising from the right interlobar artery.

Diagnosis of tuberculosis.

Presence of tuberculous infection in the body does not necessarily mean disease. Any diagnostic work up of the disease starts from a high index of clinical suspicion. However, diagnostic modalities include: (a) Isolation of the bacillus; (b) Immunologic tests; (c) Chemical markers; (d) FNAC, bronchoscopy and bronchoalveolar lavage; (e) Amplification systems. There exists controversies and limitations about the disease process even then.

Fibrothorax--problem, profile and prevention.

Fibrothorax is a common clinical condition found in everyday clinical practice. The clinical horizon of fibrothorax can be differentiated into pleural and lung parenchymal fibrosis. The two groups can be differentiated clinically and also by investigations. A thorough understanding of the process gives one better knowledge as to their different aetiologies, presentations and prognoses. The nature of prevention of this meance varies in these types. Patient's drug compliance status is important in preventing primary lung parenchymal fibrosis whereas physician's adequate care for pleural drainage is important in the prevention of pleural fibrosis. In this prospective study, observations were made on (1) the clinical presentation of 100 cases of fibrothorax and its relation to the primary disease, (2) aetiological distribution of the cases of fibrothorax and (3) scope of prevention, if any.