Langerhans Cell Histiocytosis Presenting with Pneumothorax and Diabetes Insipidus.

Secondary spontaneous pneumothoraces occur in patients with known underlying lung disease. Patients with emphysema, bullae, and cystic lesions in the lungs are at high risk of developing pneumothorax. Cystic lung diseases like Langerhans cell histiocytosis (LCH) can present with complications like pneumothorax. Other common presenting features include maculopapular rashes and bone lesions. It can also be associated with endocrinopathies, most commonly central diabetes insipidus (CDI). We here present a case of a 22-year-old male who presented with pneumothorax, polyuria, and polydipsia. He was diagnosed with LCH on transbronchial lung biopsy, associated with CDI, and was treated with thoracoscopy-guided autologous blood patch for persistent air leak and subcutaneous cytarabine.

Chronic Obstructive Pulmonary Disease and Oxygen Therapy: A Double-edged Sword.

Oxygen, like all medicines, is a drug which needs moderation. Hypoxia, as well as excess oxygen supplementation, can be harmful in a patient with chronic obstructive pulmonary disease (COPD). Both the European and the British guidelines recommend a target oxygen saturation of 88-92% in patients with COPD. Hypoxia can result in symptoms, such as restlessness, anxiety, agitation, and headache, while excess oxygen can lead to altered sensorium due to the retention of carbon dioxide (CO2) in patients with COPD. We often come across patients who come with breathlessness and have hypoxia, and the knee-jerk reaction is to start the patient on oxygen support to maintain an oxygen saturation of >95%, and this may result in hypercapnia and type II respiratory failure. Here, we present a descriptive review of the proper application of oxygen therapy in a patient presenting with acute exacerbation of COPD, the rationale behind the target oxygen saturations, and the mechanisms of type II respiratory failure due to hyperoxygenation.

Rehabilitation in obstructive sleep apnea: an ignored treatment adjunct.

Patients with obstructive sleep apnea (OSA) remain physically inactive during the day, are deconditioned, and have an impaired health-related quality of life (HRQoL). The role of rehabilitation is not yet defined in OSA, despite proven effective modalities for chronic illnesses like chronic obstructive pulmonary disease. In this prospective study, over a period of one year, 30 individuals with sleep-disordered breathing were included. Before recruitment, every patient was receiving continuous positive airway pressure treatment for at least 4 weeks. A statistically significant negative correlation was seen between the apnea hypopnea index and reductions in 6-minute walk distance, energy, and general health, which signified that patients with greater levels of daytime sleepiness have poor quality of life and are more deconditioned. Enrolled patients in the study underwent a 20-session rehabilitation program (with a minimum of 2 sessions per week). The patient received resistance and endurance exercises, dietary guidance, and counseling at each session. Before and after rehabilitation, target parameters such as 6MWD, HRQoL domains, Epworth sleepiness scale (ESS), and body mass index (BMI) were recorded. All 8 HRQoL domains showed improvement post-rehabilitation. Along with improvements in ESS and BMI, the 6MWD was also improved. No adverse event such as cardio-respiratory distress occurred in individuals undergoing rehabilitation. To conclude, rehabilitation is a safe and efficacious modality as an adjunct to positive airway pressure therapy in OSA patients.

Clinical characteristics of non-sleepy obstructive sleep apnea patients: a study in a tertiary care sleep clinic in India.

Obstructive sleep apnea (OSA) encompasses a diverse population, manifesting with or without symptoms of excessive daytime sleepiness. There is contention surrounding the significance of non-sleepy OSA within clinical contexts and whether routine treatment is warranted. This study aims to evaluate epidemiological and clinical distinctions between sleepy and non-sleepy OSA patients. A retrospective analysis was conducted on consecutive patients undergoing polysomnography for OSA assessment at tertiary care hospitals between 2018 and 2023. For 176 of 250 patients, complete polysomnography records with OSA diagnoses were available. Non-sleepy OSA was defined when a patient had an Epworth sleepiness scale score <10 and polysomnography demonstrated an apnea hypopnea index ≥5/hour. Non-sleepy OSA patients were matched with sleepy OSA patients in terms of age and gender distribution (mean age 51.24±13.25 years versus 50.9±10.87 years, male 70.4% versus 73.3%). The sensitivity of STOP-BANG≥3 for the non-sleepy OSA group was 87.7%, 89.3%, and 95.2% for any OSA severity, moderate to severe OSA, and severe OSA, respectively, while the corresponding sensitivity for the sleepy OSA group was 96.5%, 98.6%, and 100% for any OSA severity, moderate to severe OSA, and severe OSA, respectively. A novel symptom scoring tool, HASSUN (hypertension, nocturnal apneas, snoring, sleep disturbance, unrefreshing sleep, and nocturia), demonstrated a sensitivity of over 90% for all severity categories of OSA in both non-sleepy and sleepy OSA groups. The prevalence of cardiovascular and metabolic comorbidities did not significantly differ between non-sleepy and sleepy OSA patients. The physiological parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC ratio, arterial partial pressure of oxygen, and bicarbonate at baseline, were comparable between the two groups. To conclude, non-sleepy OSA patients are less obese, exhibit fewer symptoms, and have less severe OSA in comparison to sleepy OSA. Non-sleepy OSA patients display a similar likelihood of cardiovascular and metabolic comorbidities compared to sleepy OSA patients. Further investigations are warranted to elucidate the mechanisms underlying cardiovascular metabolic comorbidities in non-sleepy OSA patients. The proposed HASSUN scoring tool for non-sleepy OSA screening necessitates validation in future studies.

Thoracoscopic blood patch instillation for persistent air leak in pneumothorax: a case series and systematic review.

Persistent air leaks in patients with pneumothorax can lead to significant morbidity. If a patient with persistent air leak is medically unfit for thoracic surgery, medical pleurodesis via chest tube or thoracoscopy is either an option. Thoracoscopy offers the advantage of visualizing the site of the air leak and enabling direct instillation of the pleurodesis agent or glue at that location. Autologous blood patch instillation via chest tube has been reported to be a cheap and very effective technique for the management of persistent air leaks. However, thoracoscopic blood patch instillation has not been reported in the literature. We report two cases of secondary spontaneous pneumothorax in which patients had persistent air leaks for more than seven days and were subjected to thoracoscopy to locate the site of the leak. In the same sitting, 50 mL of autologous blood patch was instilled directly at the leak site. Post-procedure, the air leak subsided in both patients, and the chest tube was removed with complete lung expansion. We also conducted a systematic review of the use of medical thoracoscopic interventions for treating persistent air leaks.

Author Response.

How to cite this article: Ramaswamy A, Kumar R, Ish P, Gupta N. Author Response. Indian J Crit Care Med 2024;28(4):405.

Comparative yield of transbronchial cryo-nodal biopsy, transbronchial intra-nodal forceps biopsy, and transbronchial needle aspiration for mediastinal lesions at a tertiary care center in India (COLD-FORCEPS study).

Endobronchial ultrasound (EBUS) guided mediastinal cryobiopsy, and intranodal forceps biopsy are newer modalities for sampling mediastinal lymph nodes. The data regarding the diagnostic yield of both modalities is scarce. Patients were recruited retrospectively from our existing database. Patients who had undergone both an EBUS guided mediastinal cryobiopsy and an intranodal forceps biopsy were enrolled in the study. The final diagnosis was made with a clinical-pathological-radiological assessment and clinico-radiological follow-up after one month. A total of 34 patients were enrolled in the study who had undergone both EBUS guided mediastinal cryobiopsy and intranodal forceps biopsy and had complete data available, including 1-month follow-up data. The sample adequacy rate of EBUS-transbronchial needle aspiration (EBUS-TBNA), EBUS-TBNA with mediastinal cryobiopsy, and EBUS-TBNA with intranodal forceps biopsy was 94.11%, 97.05%, and 94.11%, respectively (p=0.56). The diagnostic yield achieved in EBUS-TBNA, EBUS-TBNA with mediastinal cryobiopsy, and EBUS-TBNA with intranodal forceps biopsy was 73.52%, 82.35%, and 79.41%, respectively (p=0.38). No major complications were seen in any patient. To conclude, adding EBUS guided mediastinal cryobiopsy and intranodal forceps biopsy to EBUS-TBNA may not be superior to routine EBUS-TBNA.

Clinical utility of intrabronchial antifungal instillation in a complicated case of chronic pulmonary aspergillosis: case report and systematic review of literature.

Chronic pulmonary aspergillosis (CPA) is a progressive, debilitating clinical condition associated with significant morbidity. Surgery is the mainstay of treatment for life-threatening hemoptysis in symptomatic patients with simple aspergillomas. However, in patients with chronic cavitary pulmonary aspergillosis, surgical removal of aspergillomas is fraught with difficulty due to debilitating nature of the illness. Here we present a case showcasing the utility of intrabronchial voriconazole instillation in controlling hemoptysis in a patient unfit for surgery followed by systematic review of literature involving 11 clinical studies after screening a total of 5572 studies from PubMed and Google Scholar database. Data gathered from these studies addresses the concerns regarding the efficacy, safety of the procedure as well as draws attention regarding several lacunae in our existing knowledge. A 53-year-old male with chronic pulmonary aspergillosis who had recurrent episodes of hemoptysis despite bronchial artery embolization and was unfit for surgery due to limited lung reserve, patient underwent single session of intrabronchial voriconazole instillation which resulted in dramatic symptomatic and radiological improvement. Intrabronchial antifungal instillation may be a safe and effective option for hemoptysis control in patients with chronic pulmonary aspergillosis.

Prediction of Weaning Outcome from Mechanical Ventilation Using Ultrasound Assessment of Parasternal Intercostal Muscle Thickness.

Background: Monitoring the function of parasternal intercostal muscles provides information on respiratory load and capacity and thus can be a weaning monitoring tool. Objective: The goal was to study the diagnostic accuracy of parasternal intercostal muscle thickness fraction (PICTF%) as a predictor of weaning. Materials and methods: A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. When an SBT was planned by the treating physician, the study examiner performed the ultrasound measurements of parasternal intercostal muscle thickness (inspiration and expiration) and thickening fraction using M-mode ultrasonography (USG). The PICTF% was calculated as "(peak inspiratory thickness - end-expiratory thickness)/end-expiratory thickness) × 100." Weaning failure was defined if the patient had a failed spontaneous breathing trial (SBT) or the need for a reintubation within 48 hours following extubation. The SBT failure was defined as the need to connect the patient back to the ventilator prior to its completion due to any reason as decided by the clinician. Results: Of 81 screened patients, 60 patients met the inclusion criteria, of whom 49 patients had successful SBT, and 48 patients could be successfully extubated. The PMTF% cut-off value more than or equal to 15.38% was associated with the best sensitivity (75%) and specificity (87.8%) in predicting extubation failure. Conclusion: The PICTF% has a good diagnostic accuracy in predicting weaning failure. How to cite this article: Ramaswamy A, Kumar R, Arul M, Ish P, Madan M, Gupta NK, et al. Prediction of Weaning Outcome from Mechanical Ventilation Using Ultrasound Assessment of Parasternal Intercostal Muscle Thickness. Indian J Crit Care Med 2023;27(10):704-708.

Comments on "Mucoepidermoid carcinoma of the bronchus: a rare early diagnosis".

Dear Editor, An article published in 2020 in this journal reported a rare case of a young medical student presenting with low grade mucoepidermoid carcinoma (MEC) of central airway. Curative sleeve resection was done, with negative margins and no evidence of lymph nodal involvement. The current letter presents a 3-year follow up of the same individual and a short review of the evidence available for post-resection monitoring in such patients.

Comparison of immediate withdrawal and stepwise reduction in duration of non-invasive ventilation in chronic obstructive pulmonary disease patients presenting with acute hypercapnic respiratory failure.

There is no universally acceptable protocol for the withdrawal of non-invasive ventilation (NIV) in chronic obstructive pulmonary disease (COPD) patients presenting with acute hypercapnic respiratory failure (AHcRF). This study was carried out to evaluate immediate against stepwise reduction in NIV. Sixty COPD patients with AHcRF who were managed with NIV were randomized into two groups - immediate NIV withdrawal (Group A), and stepwise reduction of NIV duration (Group B). The rate of successful NIV withdrawal, time to recurrence of hypercapnic respiratory failure, total duration of NIV use, and hospital length of stay (LOS), were compared among the 2 groups. NIV was successfully withdrawn in 51/60 (85%) patients. NIV was successfully withdrawn in 24/30 (80%) patients in Group A and 27/30 (90%) patients in Group B (p=0.472). The total duration of NIV use was significantly lower in Group A (38.97±17 hours) as compared to Group B (64.3±7.74 hours) (p<0.0001). The hospital LOS was significantly lower in group A (5.8±1.6 days) as compared to Group B (7.7±0.61 days) (p<0.0001). To conclude, immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible and does not increase the risk of weaning failure.

Post-extubation high-flow nasal cannula oxygen therapy versus non-invasive ventilation in chronic obstructive pulmonary disease with hypercapnic respiratory failure.

The sequential use of non-invasive ventilation (NIV) for weaning in hypercapnic respiratory failure patients is a recommended practice. However, the effectiveness of weaning on High flow nasal cannula (HFNC) is unclear. Chronic obstructive pulmonary disease patients with hypercapnic respiratory failure who received invasive ventilation were screened for enrolment. This study was a single-centre, prospective, randomized comparative study. The primary outcome was treatment failure within 72 hours after extubation. Patients who were screened positive for extubation were enrolled in the study and randomized into the HFNC group and NIV group using a computer-generated simple randomization chart. The treatment failure was defined as a return to invasive mechanical ventilation, or a switch in respiratory support modality (i.e., changing from HFNC to NIV or from NIV to HFNC). Of 72 patients, 62 patients were included in the study. Treatment failure occurred in 8 patients (26.67 %) in HFNC group and 8 patients in NIV group (25%) (p=0.881). The mean duration of ICU stay in HFNC group was 5.47±2.26 days and 6.56±3.39 in NIV group (p=0.376). In the current study, HFNC was non-inferior to NIV in preventing post-extubation respiratory failure in COPD patients, while HFNC had better treatment tolerance.

Multisystem inflammatory syndrome in neonates (MIS-N): a systematic review.

Recently, a new pattern of multisystem inflammatory syndrome following an infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged globally. The initial cases were described in the adult population followed by sporadic cases in the pediatric population also. By the end of 2020, similar reports were recognised in the neonatal age group. The purpose of this study was to systematically review clinical characteristics, laboratory parameters, treatment, and outcomes of neonates with multisystem inflammatory syndrome in neonates (MIS-N). A systematic review was conducted after registering with PROSPERO and electronic databases including MEDLINE, EMBASE, PubMed, SCOPUS, Google Scholar, and Web of Science were searched from January 1st 2020 till September 30th 2022. A total of 27 studies describing 104 neonates were analysed. The mean gestation age and birth weight was 35.9 ± 3.3 weeks and 2255.7 ± 783.7 g respectively. A large proportion (91.3%) of the reported cases belonged to the South-East Asian region. The median age of presentation was 2 days (range: 1-28 days) with cardiovascular system being the predominant system involved in 83.65% followed by respiratory (64.42%). Fever was noted in only 20.2%. Commonly elevated inflammatory markers were IL-6 in 86.7% and D-dimer in 81.1%. Echocardiographic evaluation suggested ventricular dysfunction in 35.8% and dilated coronary arteries in 28.3%. Evidence of SARS-CoV-2 antibodies (IgG or IgM) was seen in 95.9% neonates and evidence of maternal SARS-CoV-2 infection, either as history of COVID infection or positive antigen or antibody test, was noted in 100% of the cases. Early MIS-N was reported in 58 (55.8%) cases, late MIS-N in 28 (26.9%), and 18 cases (17.3%) did not report the timing of presentation. There was a statistically increased proportion of preterm infants (67.2%, p < 0.001), and a trend towards increased low birth weight infants, in the early MIS-N group when compared to the infants with late MIS-N. Fever (39.3%), central nervous system (50%), and gastrointestinal manifestations (57.1%) were significantly higher in the late MIS-N group (p = 0.03, 0.02, 0.01 respectively). The anti-inflammatory agents used for the treatment of MIS-N included steroids 80.8% which were given for a median of 10 (range 3-35) days and IVIg in 79.2% with a median of 2 (range 1-5) doses. The outcomes were available for 98 cases, of whom 8 (8.2%) died during treatment in hospital and 90 (91.8%) were successfully discharged home.   Conclusion: MIS-N has a predilection for late preterm males with predominant cardiovascular involvement. The diagnosis is challenging in neonatal period due to overlap with neonatal morbidities and a high risk of suspicion is warranted, especially in presence of supportive maternal and neonatal clinical history. The major limitation of the review was inclusion of case reports and case series, and highlights need of global registries for MIS-N. What is Known: • A new pattern of multisystem inflammatory syndrome following SARS-CoV-2 infection has emerged in adult population with sporadic cases now being reported in neonates. What is New: • MIS-N is an emerging condition with a heterogeneous spectrum and has a predilection for late preterm male infants. Cardiovascular system is the predominant system involved  followed by respiratory, however fever remains an uncommon presentation unlike other age-groups. There are two subtypes based on timing of presentation, with early MIS-N being reported more in preterm and low-birth weight infants.

Geriatric tuberculosis in India-challenges and solutions.

India has the highest burden of tuberculosis (TB) in the world. Despite a national program for control and elimination of TB, there is a lot to achieve to effectively diagnose and treat TB. One important aspect that often remains ignored is geriatric TB. This article focuses on the challenges in clinical presentation, diagnosis and treatment of geriatric TB along with some suggested solutions.

Comments on "Clinical, radiological and histopathological profile of patients with endobronchial lesions on fibreoptic bronchoscopy" by Sarma et al.

Dear Editor, The article by Sharma et al. regarding endobronchial biopsy in 120 patients in northern India is an attempt to understand the clinical profile, etiology and pathology of the patients who presented with endobronchial findings. The article concluded that most of the population was middle-aged males with non-small cell carcinoma being the most common diagnosis. However, there are few important points to ponder and understand in the study.

Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index.

Background: Diaphragmatic dysfunction has been increasingly documented to play a critical role to determine ventilator dependency and failure of weaning. Objective: The goal was to study the diagnostic accuracy of diaphragmatic rapid shallow breathing index (D-RSBI) as a predictor of weaning outcomes in comparison to RSBI. Materials and methods: A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. The right hemidiaphragm displacement [diaphragm displacement (DD)] was calculated by M-mode ultrasonography, and respiratory rate (RR) and tidal volume (TV) were documented from the ventilator readings. Rapid shallow breathing index (RSBI) was measured as RR/TV (in liters); D-RSBI was calculated as RR/DD (in millimeters) and expressed as breath/minute/millimeter. Extubation failure was defined as the reinstitution of mechanical ventilation at the end of, or during the spontaneous breathing trial (SBT), re-intubation or the need of noninvasive ventilation (NIV) for the patient within 48 hours of extubation. Results: Of 101 screened patients, 50 patients met the inclusion criteria, of whom 45 patients had successful SBT, and finally, 41 patients could be successfully extubated. Hence, the overall rate of weaning failure in the study population was 18%. The areas under the receiver operator characteristic (ROC) curves for D-RSBI and RSBI were 0.97 and 0.70, respectively (p <0.0001). The Pearson's correlation among RSBI and D-RSBI was 0.81 (p-value <0.001). Conclusion: Diaphragmatic rapid shallow breathing index has a positive correlation and greater diagnostic accuracy than RSBI, the conventional weaning index. How to cite this article: Shamil PK, Gupta NK, Ish P, Sen MK, Kumar R, Chakrabarti S, et al. Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index. Indian J Crit Care Med 2022;26(9):1000-1005.