Efficacy of titratable mandibular advancement device versus continuous positive airway pressure therapy in the treatment of obstructive sleep apnea: A clinical crossover trial.

Background: To compare efficacy of continuous positive airway pressure (CPAP) and oral appliance (OA) in management of various grades of obstructive sleep apnea (OSA). Methods: Thirty polysomnography diagnosed cases of OSA were divided into three groups based on baseline apnea hypopnea index (AHI) as follows: group 1: mild OSA (AHI = 5-14.9), group 2: moderate OSA (AHI = 15-29.9), and group 3: severe OSA (AHI >30) with 10 patients in each group. Half of the patients in each group were randomly allocated to CPAP or OA therapy, and crossover of therapy was performed after two months. AHI, Epworth's Sleepiness Scale (ESS), and mean oxygen saturation (SPO2) were measured at baseline, after each arm of treatment and after the crossover. A questionnaire survey including information regarding pretreatment sleep symptoms and improvement after therapy was performed at above time frames. At the end of therapy, the patients were surveyed regarding satisfaction and perceived effectiveness with both modalities. Results: CPAP was more efficacious in reducing AHI and SPO2 as compared with OA across the three study groups. The improvement in most sleep-related symptoms was higher with CPAP. The satisfaction and perception on effectiveness of treatment were higher with OA than CPAP across three study groups (P-value<0.05 for all). Conclusions: OA is an effective alternative to CPAP across all grades of OSA in selected cases, which is more preferred owing to higher effectiveness and satisfaction among the patients.

Coronavirus disease-19 triggered systemic lupus erythematous: A novel entity.

Coronavirus disease 19 (COVID-19) has been associated with varied immunological diseases due to dysregulated immune responses. We hereby report a rare case of COVID-19 triggered Systemic lupus erythematous arising in a young healthy male, necessitating the use of immunomodulatory drugs for the remission of the disease process.

Phenytoin-induced organising pneumonia: An unknown entity.

Organising pneumonia can be idiopathic or as a result of other inciting factors such as drugs. Phenytoin has been implicated in significant side effects predominantly involving extrapulmonary sites. Pulmonary side effects are reported less frequently. Hereby, we report a first case of phenytoin-induced organising pneumonia from India and evidence of significant improvement after stopping the drug.

Delayed mechanical thrombectomy after systemic thrombolysis in massive unilateral pulmonary thromboembolism.

Pulmonary thromboembolism (PTE) remains the third leading cause of cardiovascular death, after a heart attack and stroke. Haemodynamically unstable PTE (previously called high-risk or massive) is one of the dreaded conditions commonly found in people working in high-altitude areas. Due to the individual variations in clot characteristics and the haemodynamics, these patients offer unique therapeutic challenges by delay in access to tertiary care, being recalcitrant to the systemic thrombolysis as well as complete recanalisation by endovascular thrombectomy. We present a rare case of haemodynamically unstable right pulmonary trunk occlusion with delayed presentation and sustained right ventricular strain despite systemic thrombolysis, managed successfully by catheter-directed thrombectomy. Despite the partial recanalisation of only the right inferior pulmonary artery branches and persistent superior branch occlusion, there was an immediate clinical benefit and no recurrence of symptoms with maintenance therapy of newer oral anticoagulants.

Characteristics, therapeutic modalities and outcomes of COVID-19 ventilated patients in a tertiary care hospital in counter-insurgency zone: Our experience.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can result in severe life-threatening course requiring ventilatory support. This study highlights data pertaining to ventilated patients to enhance our understanding of COVID-19 as it evolves. METHODS: A descriptive, retrospective analysis was carried out on 50 COVID-19 RT-PCR positive patients who received mechanical ventilation at a tertiary care hospital in counter-insurgency (CI) zone, from June to December 2020. Data pertaining to patient characteristics, treatment, ventilator support and outcomes was analysed. RESULTS: Out of 50 patients, 74% were aged 50 years and above with 60% patients having comorbidities. 39 patients received non-invasive ventilation (NIV) and 04 patients received invasive mechanical ventilation (IMV) while 07 patients were converted from NIV to IMV during the hospital stay. Out of the 50 patients who received ventilator support 25 (50%) survived to discharge. The overall survival was 47.3% amongst the males while it was 58.3% for the females. The majority of survivors were in the NIV category (61.5%) while only 9.0% survived amongst those who received IMV. Average length of stay on NIV for patients was 5.3 days and for IMV was 7.5 days. All 50 patients received therapy in the form of steroids, anticoagulants, broad spectrum antibiotics and antivirals. Remdesivir was given to 40 of these patients out of which 20 survived (50%). Interleukin-6 therapy (Tocilizumab) was given to five patients of which four survived (80%). CONCLUSION: This study helps us to gain insights into the outcomes of COVID-19 patients managed in a tertiary care hospital in CI zone.

Diagnostic Yield and Safety of Bronchoscopic Lung Cryobiopsy in Evaluation of Lung Mass.

Background A mass lesion in the lung is a common finding seen on chest radiology. The prognosis of patients with mass lesions in the lung is capricious as malignancy is a consideration. It is essential to diagnose the underlying aetiology at the earliest with minimally invasive procedures for prompt treatment of the case. Bronchoscopic lung cryobiopsy (BLC) is a newer interventional technique in pulmonary medicine for the diagnosis of mass lesions in the lung. Materials and methods This is a retrospective study of patients reporting to a tertiary care centre who were radiologically (by computed tomography scan of the chest) diagnosed with a mass lesion of the lung and who underwent BLC during the period from January 2018 to January 2021. We analysed the diagnostic yield of the technique defined as a positive tissue diagnosis after the histopathological examination (HPE) along with the safety of the procedure. Results During the above period, we evaluated 70 patients who were diagnosed radiologically with mass lesions of the lung and underwent BLC. We obtained tissue diagnoses for 66 cases and the result of four cases was inconclusive. The diagnostic yield of the BLC procedure was 94.29%. There was no mortality and complications were minimal bleeding and small pneumothorax. Conclusion BLC is a newer technique for obtaining lung tissue via a flexible bronchoscope obviating the need for open lung biopsy. The main advantage of the technique is providing larger tissue samples with minimal or no side effects without undergoing multiple procedures as compared to other bronchoscopic or surgical methods for obtaining a diagnosis from lung tissue. BLC is a safer and promising technique in diagnosing mass lesions of the lung with better yield.

Exhaled nitric oxide as a guiding tool for bronchial asthma: A randomised controlled trial.

BACKGROUND: Evidence regarding the role of non-invasive marker of airway inflammation, fractional exhaled nitric oxide (FeNO) to guide asthma treatment is equivocal. We aimed to evaluate if the use of FeNO to adjust inhaled corticosteroid treatment resulted in reduced daily corticosteroid use and lesser exacerbations. METHODS: 100 patients of bronchial asthma in the age group of 12-70 years were randomised to receive inhaled corticosteroids based on either FeNO measurements (n = 50) or as per Global Initiative for Asthma (GINA) guidelines. Follow up was done every 2 months for period of 12 months. Results were compared in terms of mean daily inhaled corticosteroid use and number of exacerbations. RESULTS: After the follow up period of 12 months, mean daily dose of ICS (SD) required in FeNO group was 267.5 µg (126.29), as opposed to control group in which mean daily dose of steroid was 320.00 µg (138.69). However this observed difference in steroid dose was statistically insignificant (p value = 0.061). The estimated mean (SD) rate of asthma exacerbation experienced in follow up period of 12 months in FeNO group was 0.3 episodes (0.54) per patient per year (95% confidence interval, 0.145-455) and 0.4 episodes (0.61) per patient per year in control group (95% confidence interval, 0.228-572). However this difference in rate of exacerbations between the two study groups was not statistically significant (p = 0.387). CONCLUSION: FeNO guided management strategy for asthma did not result in statistically significant reduction in dose of inhaled corticosteroids or number of asthma exacerbations.

An unknown cause of hemoptysis-Left anterior descending coronary artery to left upper lobe bronchus fistula.

We report a case of left anterior descending coronary artery to left upper lobe bronchus fistula arising out of the coronary artery aneurysm, secondary to drug eluting balloon angioplasty done for in-stent restenosis in the left anterior descending coronary artery in a 54-year-old male. This is an unreported entity yet.

Closure of chronic bronchopleural fistula using atrial septal occluder device.

Chronic persistent bronchopleural fistulae (BPF) are challenging management problems. The management of BPF includes various surgical and medical procedures and of great value is the use of bronchoscopy and different devices. In high-risk surgical patients, bronchoscopic procedures serve as a temporary bridge until the patient's clinical condition improves, whereas in other patients bronchoscopic procedures may be the only option. We present a case of postoperative chronic BPF closed by a less invasive interventional bronchoscopic procedure using an atrial septal occluder device.