Awareness of issues related to sleep disordered breathing amongst practicing physicians.

BACKGROUND: Most of the sleep related breathing disorders currently in India are both under diagnosed and under treated. The exact prevalence of sleep disordered breathing (SDB) in our country is not clearly known and this is partly due to lack of awareness amongst physicians and lack of formal epidemiological data from Indian subcontinent. Several international agencies have emphasised the urgent need for medical training at all levels in sleep medicine, so as to include an exposure to the broader aspects of sleep medicine. OBJECTIVE: To assess the knowledge of practicing chest physicians on the issues related to sleep disordered breathing in the local set-up. METHODS: A standardised questionnaire with strong face validity was utilised for this purpose to interview 65 physicians at their work place. RESULTS: The overall awareness about sleep disordered breathing amongst the practicing physicians in Hyderabad, Secunderabad and the neighbouring district of Warangal was poor. There was no association between professsional qualifications and level of awareness. Furthermore, the awareness was found to be similarly low both amongst young and middle aged physicians and this was statistically significant (p<0.001). CONCLUSION: The overall awareness about sleep disordered breathing amongst practicing physicians in and around Hyderabad is rather poor.

Adenoid cystic carcinoma of trachea.

A 20-year-old male, presented with cough, haemoptysis, breathlessness and wheezing for the past one month. Contrast enhanced computerised tomographic (CECT), scan of chest and fibreoptic bronchoscopy revealed an endotracheal mass that on histopathological examination showed adenoid cystic carcinoma of trachea. Magnetic resonance imaging (MRI) scan of chest confirmed involvement of adjacent prevertebral, para-oesophageal and subcarinal lymph nodes rendering the tumour inoperable.

Sleep in Type 2 diabetes.

OBJECTIVES: To examine the relationship between glycemic control in Type 2 diabetics and sleep duration and quality of sleep. METHODS: There were 220 adult non-insulin dependent diabetics (Type 2) with 69 males and 151 females. The mean age was 59.4 +/- 9.2 yrs (Mean +/- SD), mean BMI 35.6 +/- 9.9 kg/m2, and mean HbA1c 8.2 +/- 2.1%. Detailed questions about history and management of diabetes, height, weight and the Pittsburgh Sleep Quality Index (PSQI) were obtained to measure subjective sleep quality. HbA1c data were obtained to measure glycemic control in the past three months. RESULTS: The mean amount of self-reported sleep was 6.10 +/- 1.66 hours. The mean difference between preferred and actual weekday sleep was 1.83 +/- 2.01 hours indicating significant perceived sleep debt. The mean Pittsburgh Sleep Quality Index (PSQI) score was 8.3 and 71% of patients had a score of > 5 which is clinically diagnostic for poor sleep. CONCLUSION: A significant proportion of Type 2 diabetics have reduced sleep and there is a definite association between glycemic control and both quality and quantity of sleep.

Obstructive sleep apnea in a referral population in India.

There are few published studies of obstructive sleep apnea in the Asian subcontinent. The objectives were to describe the syndrome and evaluate the utility of computed tomography (CT) cephalometry in patients found to have obstructive sleep apnea (OSA) by polysomnography. This article reports on a retrospective case series in a referral population. A total of 880 patients (560 males and 320 females) were seen in a referral center in Hyderabad, South India, during the last 7 years. All patients with suspected obstructive sleep apnea were evaluated with 16-channel polysomnogram by overnight sleep study; 600 subjects (68%; 480 males and 120 females) underwent evaluation with CT cephalometry. Mean age was 51.4 +/- 9.5 years (standard deviation). The mean apnea-hypopnea index (AHI) was 27.93 +/- 3.8. The majority of patients had more than 10 AHI; mean percentage of sleep efficiency was 80.62 +/- 15.38; mean percentage of rapid eye movement (REM) sleep was 13.79 +/- 7.89; mean awake arterial oxygen saturation (SaO2) was 90%; mean sleep SaO2 was 84% +/- 4.4%; mean Epworth Sleepiness Scale (ESS) score was 12.3 +/- 2.8. The tongue base area (TBA) was found to be significantly associated with obstructive sleep apnea (OSA), with mean TBA 1032.8 +/- 427 mm2 compared with normal controls at 561.1 +/- 197.6 mm2 (p < 0.001). Mean gonion-gnathion-hyoid angle (Go-Gn-H) was 28.5 +/- 10.5 in OSA and 16 +/- 16.7 in controls; uvula area was 452.5 +/- 145.8 mm2 in OSA and 221.4 +/- 49.85 mm2 in controls; uvula diameter was 13.8 +/- 2.74 mm in OSA and 10.1 +/- 1.72 mm in controls. A total of 704 patients with OSA (80%) were found to be hypertensive, with daytime mean blood pressure of 160/100 +/- 8.5/4.8 mm Hg. Mean duration of reported hypertension was 2 years. The present study showed moderate to severe OSA in a majority of suspected cases referred for polysomnogram. Mild disease was seen in 20.45% of patients (n = 180). On CT cephalometry, the TBA correlated significantly with OSA; hypertension is common in patients with OSA.

Clinical profile of ARDS.

OBJECTIVES: Several studies have been published in western literature on incidence, prevalence, clinical course, outcome and mortality in patients with acute respiratory distress syndrome (ARDS). There are very few studies on the pattern of ARDS seen in Indian population. There are anecdotal reports of ARDS associated with different tropical diseases and the exact association of these life-threatening disorders with ARDS is not clearly described in the Indian literature. The study was carried out to identify the clinical pattern of Indian patients who died of ARDS. METHODS: This was a three and a half year retrospective study comprising of 98 patients who died of ARDS in the intensive care unit of Apollo Hospital, a tertiary care referral centre between January 1999 to June 2002. The present study looked at only those patients who died from ARDS and did not evaluate the clinical outcome or survival pattern of ARDS patients. The criteria used for diagnosis of ARDS was based upon American/European consensus statement for definition of acute lung injury (ALI) and ARDS. The patient demographic data consisted of age, sex, associated major illness in the part, clinical disorders associated with ARDS, length of hospital stay, use and duration of mechanical ventilation and the presence of sepsis and organ failure defined by ACCP/SCCM consensus conference definition. Seventy patients were ventilated with volume control mode and 28 patients with pressure control ventilation. Lung protective strategy was used in all the cases comprising of low tidal volumes at the rate of 5-ml/kg-body weight. Statistical analysis of the data was done by SPSS 10 for windows (SPSS, Inc., Chicago, Illinois). RESULTS: There were 98 patients during the study period who died of ARDS. Fifty one males and 47 female patients. Thirty patients had primary pulmonary infection, 18 had severe sepsis with multiorgan failure, 12 patients had polytrauma and 10 each had recent abdominal surgery and pancreatitis. Length of ICU stay was less than 10 days in 58 patients whereas in 40 patients it was more than 10 days. Duration of mechanical ventilation was less than seven days in 80 patients and more than seven days in 18 patients. Positive body fluid cultures were obtained in 42 out of 98 patients and of these, 14 patients had microbiological diagnosis established by blood culture, another 14 by endotracheal secretion culture, eight by urine culture and in the remaining six patients based upon wound cultures. The commonest organisms isolated from the body fluids were Pseudomonas and Klebsiella. CONCLUSION: Primary pulmonary infection was associated with ARDS is one-third of patients. Multiorgan failure was seen in 18% of patients who died from ARDS. Severe sepsis was identified as a significant risk factor for ARDS.

Pattern of lung cancer in elderly.

OBJECTIVES: The aim of the study was to evaluate the clinical spectrum of the lung cancer in the Indian patients. METHODS: All the patients above the age 60 years referred to the chest clinic of Apollo Hospitals, during the period 1989-2000 were evaluated for lung cancer with fibreoptic bronchoscopy, fluoroscopic guided transbronchial lung biopsy, transbronchial, needle aspiration and/or CT guided percutaneous fine needle aspiration biopsy. Retrospective data of 1400 patients was analyzed statistically. RESULTS: There were 512 patients (439 males, 73 females) with confirmed primary lung cancer. There were 62% ex-smokers, 10% current smokers and 28% non-smokers amongst males, whereas amongst females there were 10% ex-smokers and 90% non-smokers. Cough of more than 3 weeks duration was the commonest symptom seen in 85% (n = 435) followed by fever and weight loss. Radiologically the commonest feature was collapse-consolidation in 77% (n = 397). Central endobronchial tumours were seen in 204 patients (39.8%), whereas peripheral tumours were seen in 308 (60.2%). The diagnostic yield of transbronchial lung biopsy alone was as high as 48%, whereas the yield on CT guided percutaneous fine needle aspiration biopsy alone ranged from 32%-40%. There was no statistical difference in histological subtypes (non-small cell or small cell lung cancer) in the various groups studied. However, in those patients above the age of 80 years (group C) small cell lung cancer was more frequently seen. CONCLUSION: Primary lung cancer should always be suspected in elderly Indian subjects with unexplained cough and other constitutional symptoms of weight loss and fever.