Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Logistic regression analysis of environmental and other variables and incidences of tuberculosis in respiratory patients.

The objective of this study was to examine the association of 14 variables with TB in respiratory patients. The variables included: urban/rural, persons in 1200 sqft area, TB in family, crowding, smoking (family member), gender, age, education, smoking, workplace, kitchen location, cooking fuel, ventilation, and kerosene uses. Eight hundred respiratory patients were tested for sputum positive pulmonary TB; 500 had TB and 300 did not. An analysis of the unadjusted odds ratio (UOR) and adjusted OR (AOR) was undertaken using logistic regression to link the probability of TB incidences with the variables. There was an inconsistency in the significance of variables using UOR and AOR. A subset model of 4 variables (kerosene uses, ventilation, workplace, and gender) based on significant AOR was adjudged acceptable for estimating the probability of TB incidences. Uses of kerosene (AOR 2.62 (1.95, 3.54)) consistently related to incidences of TB. It was estimated that 50% reduction in kerosene uses could reduce the probability of TB by 13.29% in respiratory patients. The major recommendation was to replace kerosene uses from households with a supply of clean fuel like liquid petroleum or natural gas and rural electrification.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP).

BACKGROUND: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. METHODS: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. RESULTS: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. CONCLUSION: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP)

Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. Methods: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. Results: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. Conclusion: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

Hypersensitivity pneumonitis: Clinical manifestations - Prospective data from the interstitial lung disease-India registry.

CONTEXT: Multiple environmental factors are associated with development of hypersensitivity pneumonitis (HP), and diagnostic algorithms for the diagnosis of HP have been proposed in recent perspectives. AIMS: We analyzed the data of patients with HP from interstitial lung disease (ILD)-India registry. The analysis was performed to (1) find the prevalence of HP, (2) reclassify HP as per a recently proposed classification criterion to assess the level of diagnostic certainty, and (3) identify the causative agents for HP. SETTING AND DESIGNS: This was a prospective multicenter study of consecutive, consenting adult patients with new-onset ILD from 27 centers across India (March 2012-April 2015). MATERIALS AND METHODS: The diagnoses were based on prespecified working clinical criteria and multidisciplinary discussions. To assess strength of diagnosis based on available clinical information, patients with HP were subclassified into definite HP, HP with high level of confidence, and HP with low level of confidence using a recent classification scheme. RESULTS: Five hundred and thirteen of 1084 patients with new-onset ILD were clinically diagnosed with HP and subclassified as HP with high level of confidence (380, 74.1%), HP with low level of confidence (106, 20.7%), and definite HP (27, 5.3%). Exposures among patients with HP were birds (odds ratios [OR]: 3.52, P < 0.001), air-conditioners (OR: 2.23, P < 0.001), molds (OR: 1.79, P < 0.001), rural residence (OR: 1.64, P < 0.05), and air-coolers (OR: 1.45, P < 0.05). CONCLUSIONS: About 47.3% of patients with new-onset ILD in India were diagnosed with HP, the majority of whom were diagnosed as HP with a high level of confidence. The most common exposures were birds, cooling devices, and visible molds.

Pyrazinamide-induced phototoxicity: a case report and review of literature.

A 40-year-old male presented with a fresh case of pulmonary tuberculosis and itchy oozing rashes distributed characteristically over the sun exposed areas of the skin. These rashes had developed since six days following 10 days of start of antitubercular drugs (streptomycin, isoniazid, rifampicin, pyrazinamide and ethambutol at standard dosages). A possibility of drug-induced reaction was entertained and all the antitubercular drugs were discontinued; subsequently they were reintroduced in a sequential manner starting with small dosages, gradually increasing them to their normal dose. The rashes reappeared after introduction of pyrazinamide. We tried to desensitize this very important antitubercular drug but were not successful as the rashes reappeared. The patient was labeled as having pyrazinamide-induced phototoxicity and was started on a regimen containing streptomycin, isoniazid, rifampicin, ethambutol. Five months following treatment, the patient is now sputum negative for AFB. Pyrazinamide forms the integral part of most of the short course regimens, included in all the three categories of DOTS and with increasing coverage of DOTS therapy these rare cases may well be frequently encountered.

Effects of particulate air pollution on the respiratory health of subjects who live in three areas in Kanpur, India.

In this study, the authors assessed the relationship between daily changes in respiratory health and particulate levels with diameters of (a) less than 10 microm (PM10) and (b) less than 2.5 microm (PM2.5) in Kanpur, India. The subjects (N = 91) were recruited from 3 areas in Kanpur: (1) Indian Institute of Technology (Kanpur), which was a relatively clean area; (b) Vikas Nagar, a typical commercial area; and (c) finally, the residential area of Juhilal Colony. All subjects resided near to air quality monitoring sites. Air quality and peak expiratory flow rate samplings were conducted for 39 d. Once during the sampling period, lung-function tests (i.e., forced expiratory volume in 1 s, forced vital capacity) were performed on each subject. Subjects who resided at the clean site performed at predicted (i.e., acceptable) values more often than did subjects who lived at the remaining 2 sites. Subjects who lived at all 3 sites demonstrated a substantial average deficit in baseline forced vital capacity and forced expiratory volume in 1 s values. The authors used a statistical model to estimate that an increase of 100 microg/m3 of the pollutant PM10 could reduce the mean peak expiratory flow rate of an individual by approximately 3.2 l/min.