Efficacy of pulmonary telerehabilitation on exercise tolerance, fatigue, perceived exertion, depression, and quality of life in COVID-19 survivors / Eficácia da telereabilitação pulmonar na tolerância ao exercício, fadiga, percepção de esforço, depressão e qualidade de vida em sobreviventes de COVID-19

INTRODUCTION: Telerehabilitation advanced significantly with the emergence of COVID-19 and the recommendation of limiting physiotherapist-patient contact time whenever practicable. The effectiveness of telerehabilitation on those who had a longer stay in hospital and on oxygen support following discharge is still under question. OBJECTIVES: To evaluate the effects after six weeks of pulmonary telerehabilitation on exercise tolerance, fatigue level, perceived exertion, symptoms of depression and quality of life in patients surviving COVID-19. MATERIALS AND METHODS: A quasi-experimental study was conducted on 25 post-COVID-19 patients following discharge in a home environment setting. The participants were advised to prepare equipment such as oxygen concentrator, B-type oxygen cylinder (backup), lengthy oxygen tubes, finger pulse oximeter, mini static pedal exerciser, incentive spirometry, weight cuffs or water bottles and sandbags. After six weeks of telerehabilitation, the patients underwent assessments including initial oxygen saturation (SPO2), heart rate, peak oxygen demand during exercise to maintain baseline SPO2, peak heart rate, maximum drop in SPO2, recovery time to baseline SPO2 measured with a pulse oximeter and stopwatch, peak perceived exertion using the Borg Dyspnea Scale, peak fatigue score using the visual analog scale (VASF), quality of life assessed with the SF-36 questionnaire, and mental health status evaluated with the Hamilton Depression Scale (HAMD). One-way repeated measure ANOVA and paired t-test were used. RESULTS: Significant improvements following the intervention on the initial SPO2 (F (2.12, 23.13) = 21.0, p< 0.05) and quality of life also showed significant improvement (mean difference =29.92, p< 0.05). CONCLUSION: Six weeks of comprehensive pulmonary telerehabilitation with simple equipment improved tolerance to exercise, fatigue, perceived exertion, symptoms of depression and quality of life for post-COVID-19 patients.

INTRODUÇÃO: A telereabilitação avançou significativamente com o surgimento da COVID-19 e a recomendação de limitar o tempo de contato entre fisioterapeutas e pacientes sempre que possível. A eficácia da telereabilitação em pacientes que permaneceram mais tempo no hospital e necessitaram de suporte de oxigênio após a alta ainda está em questão. OBJETIVO: Para avaliar os efeitos após seis semanas de telereabilitação pulmonar na tolerância ao exercício, nível de fadiga, percepção de esforço, sintomas de depressão e qualidade de vida em pacientes sobreviventes de COVID-19. MATERIAIS E MÉTODOS: Foi realizado um estudo quase-experimental com dezesseis pacientes pós-COVID-19 selecionados de um hospital multispecializado. Os participantes foram orientados a preparar equipamentos como concentrador de oxigênio, cilindro de oxigênio tipo B (reserva), tubos de oxigênio longos, oxímetro de pulso, exercitador de pedal estático, espirômetro incentivador, pesos de tornozelo ou garrafas d'água e sacos de areia. Após seis semanas de telereabilitação, os pacientes foram submetidos a avaliações, incluindo saturação inicial de oxigênio (SPO2), frequência cardíaca, demanda máxima de oxigênio durante o exercício para manter a SPO2 basal, frequência cardíaca máxima, queda máxima na SPO2, tempo de recuperação para SPO2 basal medido com um oxímetro de pulso e cronômetro, esforço percebido máximo usando a Escala de Dispneia de Borg, pontuação máxima de fadiga usando a escala analógica visual (VASF), qualidade de vida avaliada com o questionário SF-36 e estado de saúde mental avaliado com a Escala de Depressão de Hamilton (HAMD). RESULTADOS: Melhorias significativas após a intervenção foram observadas na SPO2 inicial (F (2,12, 23,13) = 21,0, p <0,05) e na frequência cardíaca (F (1,839, 20,23) = 43,73, p <0,05), demanda máxima de oxigênio durante o exercício para manter a SPO2 basal (F (1,487, 16,36) = 8,96, p <0,05), esforço percebido máximo (F (5, 55) = 112,51, p <0,05), pontuação máxima de fadiga (F (1,755, 19,30) = 67,44, p <0,05), frequência cardíaca máxima (F (1,798, 19,78) = 50,99, p <0,05), queda máxima na SPO2 (F (2,467, 27,14) = 41,46, p <0,05) e tempo máximo de recuperação para alcançar a SPO2 basal (F (5, 55) = 78,89, p <0,05). A análise de seis semanas pós-intervenção nos sintomas depressivos (diferença média = 11,25, p <0,05) e na qualidade de vida também mostrou melhoria significativa (diferença média = 29,92, p <0,05). CONCLUSÃO: Seis semanas de telereabilitação pulmonar abrangente com equipamentos simples melhoraram a tolerância ao exercício, a fadiga, a percepção de esforço, os sintomas de depressão e a qualidade de vida em pacientes pós-COVID-19.

Clinical outcomes of bronchiectasis in India: data from the EMBARC/Respiratory Research Network of India registry.

BACKGROUND: Identifying risk factors for poor outcomes can help with risk stratification and targeting of treatment. Risk factors for mortality and exacerbations have been identified in bronchiectasis but have been almost exclusively studied in European and North American populations. This study investigated the risk factors for poor outcome in a large population of bronchiectasis patients enrolled in India. METHODS: The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India (EMBARC-India) registry is a prospective observational study of adults with computed tomography-confirmed bronchiectasis enrolled at 31 sites across India. Baseline characteristics of patients were used to investigate associations with key clinical outcomes: mortality, severe exacerbations requiring hospital admission, overall exacerbation frequency and decline in forced expiratory volume in 1 s. RESULTS: 1018 patients with at least 12-month follow-up data were enrolled in the follow-up study. Frequent exacerbations (≥3 per year) at baseline were associated with an increased risk of mortality (hazard ratio (HR) 3.23, 95% CI 1.39-7.50), severe exacerbations (HR 2.71, 95% CI 1.92-3.83), future exacerbations (incidence rate ratio (IRR) 3.08, 95% CI 2.36-4.01) and lung function decline. Coexisting COPD, dyspnoea and current cigarette smoking were similarly associated with a worse outcome across all end-points studied. Additional predictors of mortality and severe exacerbations were increasing age and cardiovascular comorbidity. Infection with Gram-negative pathogens (predominantly Klebsiella pneumoniae) was independently associated with increased mortality (HR 3.13, 95% CI 1.62-6.06), while Pseudomonas aeruginosa infection was associated with severe exacerbations (HR 1.41, 95% CI 1.01-1.97) and overall exacerbation rate (IRR 1.47, 95% CI 1.13-1.91). CONCLUSIONS: This study identifies risk factors for morbidity and mortality among bronchiectasis patients in India. Identification of these risk factors may support treatment approaches optimised to an Asian setting.

Miliary Sarcoidosis: does it exist? A case series and systematic review of literature.

BACKGROUND AND OBJECTIVES: Sarcoidosis typically presents with peribronchovascular and perilymphatic nodules on high-resolution computed tomography (HRCT); a miliary pattern is reported but not well described. DESIGN SETTING: We describe four patients with miliary sarcoidosis and results of a systematic review of all previously reported cases from 1985 onwards. RESULTS: We identified only 27 cases of "miliary" sarcoidosis in the HRCT era. These patients were older (85.2% older than 40 years), had more co-morbidities (72.7%) and were symptomatic compared to "typical" sarcoidosis. Respiratory symptoms were present in 61.9% at diagnosis. Hypercalcemia was seen in 28.5%. On review of HRCT images, only 34.6% (9/26) had a "true miliary" pattern without fissural nodules. In our series, prominent perivascular granulomas were seen on histopathology in all. 44.4% (12/27) had tuberculosis preceding or concurrent to miliary sarcoidosis. Of the eight true associations, tuberculosis preceded sarcoidosis by 52 (median, IQR 36) weeks in six and occurred concurrently in another two. The diagnosis of tuberculosis was clinical in all with concurrent diagnosis of tuberculosis and sarcoidosis. Treatment with steroids had 100% response and 14.2% relapse. CONCLUSIONS: A true miliary pattern in the HRCT era is very rare in sarcoidosis and subtle perilymphatic pattern is nearly always seen; this should be labeled "pseudo-miliary". Prominent perivascular granulomas are associated with true miliary pattern. Miliary sarcoidosis patients are older and symptomatic, needing treatment at diagnosis. "Miliary" sarcoidosis may follow treatment for tuberculosis; concurrent cases possibly indicate the difficulty in differentiating both or a "tuberculo-sarcoid" presentation. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 53-65).

Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease.

BACKGROUND: Pulmonary nocardiosis (PN) occurs in chronic pulmonary disease (CPD) in the absence of traditional risk factors. Clinical features that differentiate bacterial exacerbations (AE-CPDb) from PN-related exacerbations (AE-CPDPN) are not well described. OBJECTIVES: To describe a series of AE-CPDPN without traditional risk factors and compare clinical features, radiology and outcomes with age, gender and CLD-type matched AE-CPDb. MATERIALS AND METHODS: Single-center retrospective review and case-control study. RESULTS: AE-CPDPN had longer duration of symptoms and more leukocytosis at hospitalization. AE-CPDb patients were sicker with more chronic respiratory failure (OR 33.3, p = 0.01), cardiac disease and pulmonary hypertension (OR 6.2, p = 0.008) at diagnosis. More patients with AE-CPDb were discharged on domiciliary oxygen (OR 5.27, p = 0.01). On logistic regression, AE-CPDPN was independently associated with mechanical ventilation (OR 22.3, p = 0.01), length of hospital stay (median difference, 4 days, p = 0.016) but not to hospital mortality. 22.7% of AE-CPDPN died. Respiratory failure requiring oxygen, NIPPV or mechanical ventilation was associated with mortality in AE-CPDPN. CONCLUSION: PN is a rare cause of AE-CPD and can be suspected by longer symptom duration, more leukocytosis, consolidation and cavitation. AE-CPDPN is associated with longer hospital stay and mechanical ventilation. Respiratory failure is associated with mortality in AE-CPDPN. KEY MESSAGES: Pulmonary nocardiosis can present in advanced chronic lung disease as an exacerbation in the absence of traditional risk factors like immunosuppression.Bronchiectasis, followed by chronic obstructive pulmonary disease are the most common chronic lung disease risk factors.Pulmonary nocardiosis is a rare cause of acute exacerbation of chronic pulmonary disease (CPD).Compared to exacerbations of CPD due to bacterial infections, nocardiosis-related exacerbations (CPDPN) were independently related to need for mechanical ventilation and length of hospital stay.Respiratory failure requiring oxygen, noninvasive ventilation and mechanical ventilation are associated with mortality in AE-CPDPN. HOW TO CITE THIS ARTICLE: Kancherla R, Ramanathan RM PL, Appalaraju B, Srinivas R. Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease. Indian J Crit Care Med 2019;23(10):467-474.

Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India Registry.

BACKGROUND: Bronchiectasis is a common but neglected chronic lung disease. Most epidemiological data are limited to cohorts from Europe and the USA, with few data from low-income and middle-income countries. We therefore aimed to describe the characteristics, severity of disease, microbiology, and treatment of patients with bronchiectasis in India. METHODS: The Indian bronchiectasis registry is a multicentre, prospective, observational cohort study. Adult patients (≥18 years) with CT-confirmed bronchiectasis were enrolled from 31 centres across India. Patients with bronchiectasis due to cystic fibrosis or traction bronchiectasis associated with another respiratory disorder were excluded. Data were collected at baseline (recruitment) with follow-up visits taking place once per year. Comprehensive clinical data were collected through the European Multicentre Bronchiectasis Audit and Research Collaboration registry platform. Underlying aetiology of bronchiectasis, as well as treatment and risk factors for bronchiectasis were analysed in the Indian bronchiectasis registry. Comparisons of demographics were made with published European and US registries, and quality of care was benchmarked against the 2017 European Respiratory Society guidelines. FINDINGS: From June 1, 2015, to Sept 1, 2017, 2195 patients were enrolled. Marked differences were observed between India, Europe, and the USA. Patients in India were younger (median age 56 years [IQR 41-66] vs the European and US registries; p<0·0001]) and more likely to be men (1249 [56·9%] of 2195). Previous tuberculosis (780 [35·5%] of 2195) was the most frequent underlying cause of bronchiectasis and Pseudomonas aeruginosa was the most common organism in sputum culture (301 [13·7%]) in India. Risk factors for exacerbations included being of the male sex (adjusted incidence rate ratio 1·17, 95% CI 1·03-1·32; p=0·015), P aeruginosa infection (1·29, 1·10-1·50; p=0·001), a history of pulmonary tuberculosis (1·20, 1·07-1·34; p=0·002), modified Medical Research Council Dyspnoea score (1·32, 1·25-1·39; p<0·0001), daily sputum production (1·16, 1·03-1·30; p=0·013), and radiological severity of disease (1·03, 1·01-1·04; p<0·0001). Low adherence to guideline-recommended care was observed; only 388 patients were tested for allergic bronchopulmonary aspergillosis and 82 patients had been tested for immunoglobulins. INTERPRETATION: Patients with bronchiectasis in India have more severe disease and have distinct characteristics from those reported in other countries. This study provides a benchmark to improve quality of care for patients with bronchiectasis in India. FUNDING: EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative inhaled Antibiotics in Bronchiectasis and Cystic Fibrosis Consortium, European Respiratory Society, and the British Lung Foundation.

An unusual cause of breathlessness and profuse micronodules.

We describe a 21-year-old male with a history of smoking and subacute onset of breathlessness with normal cardiorespiratory examination. The presence of "track marks" and digital infarcts prompted evaluation for infective endocarditis and confrontational history taking revealed anorexia, weight loss over 3 months along with intravenous drug abuse of reconstituted tablets of tapentadol. Echocardiography was normal and blood cultures were sterile; computed tomography showed bilateral, diffuse, small centrilobular nodules with "tree-in-bud" appearance. In this clinicopathologic conference, we discuss the clinical and radiological differential diagnosis of centrilobular nodules, lung biopsy findings, and management options for patients with such a presentation.

Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature.

Tuberculosis (TB) is a rare cause of chylothorax. We describe a case and the results of a systematic review of all reported cases of TB-chylothorax. We identified 37 cases of TB-chylothorax. The symptoms at presentation were constitutional (85.7%; 30/35), dyspnea (60.6%; 20/33), and cough (54.5%; 18/33). Chylothorax developed subsequent to the diagnosis of TB in 27.8% (10/36) of the patients, after a median of 6.75 weeks (IQR 4-9). Chylothorax developed during an immune reconstitution syndrome (IRS) in 16.7% (10/36) of the patients, including immunocompetent ones. TB was disseminated in 45.9% (17/37) of the patients at the diagnosis of chylothorax. Chylothorax developed in the absence of any mediastinal lymphadenopathy in 45.9% (17/37) of the patients; 13.5% (5/37) had isolated tubercular empyema alone. The diagnosis of TB was established microbiologically in 72.2% (26/36) and by biopsy alone in 27.8% (9/36) of the patients. Anti-TB treatment (ATT) was administered for a median of 7.57 months (IQR 6-9). Steroids were administered to 22.9% (8/35) of the patients, often for suspected IRS. Thoracic duct ligation and octreotide were required for only 17.1% (6/35) and 8.6% (3/35) of the patients, respectively. In all, 94.4% (34/36) of the patients had resolution of chylothorax and completed treatment successfully; only 5.6% (2/36) died. In conclusion, TB-chylothorax may develop without obvious mediastinal lymphadenopathy and be associated with tubercular empyema alone. TB-chylothorax can develop during treatment of TB due to IRS, even in immunocompetent patients. ATT and dietary manipulation are associated with good resolution and low mortality, and duct ligation is needed for only a small minority of patients.