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   Table of Contents - Current issue
Coverpage
July-December 2020
Volume 9 | Issue 2
Page Nos. 129-248

Online since Tuesday, July 7, 2020

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EDITORIAL  

Challenges with present symptom control and risk reduction of future exacerbations in asthma: Indian patients' perspectives p. 129
MM Harish, BM Ramya
DOI:10.4103/ijrc.ijrc_64_19  
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“Happy hypoxia” of COVID-19: Are we happy with our oxygen reserves? Highly accessed article p. 131
Souvik Chaudhuri, Vishal Shanbhag, Anitha Nileshwar
DOI:10.4103/ijrc.ijrc_58_20  
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REVIEW ARTICLES Top

High-flow nasal cannula: COVID 19 and beyond Highly accessed article p. 134
Aniket Shitalkumar Rali, Taylor Garies, Dharani Narendra, Purvesh Patel, Kalpalatha Guntupalli
DOI:10.4103/ijrc.ijrc_47_20  
Early case series have suggested that 20%–31% of COVID-19 patients will develop acute respiratory distress syndrome and require intensive care, potentially causing a nationwide shortage of mechanical ventilators. We present a review of the high-flow nasal cannula which presents several physiological benefits in acute respiratory failure. It is a safe treatment modality with low risk of exposure to aerosolized viral particles for health-care workers in the setting of negative-pressure or high-efficiency particulate air-filtered rooms and proper personal protective equipment.
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Lung ultrasound in critical care p. 141
Souvik Chaudhuri, Maddani Shanmukhappa Sagar, Sirish Gauni, Vedaghosh Amara, Tushar Mittal
DOI:10.4103/ijrc.ijrc_26_20  
Point of care ultrasound for critically ill patients in intensive care unit has enabled clinicians to expedite the process of diagnosis and treatment without exposing the patient to any of the harmful radiations. Lung ultrasound (LUS) ensures an accurate assessment of the disease pathology, is easy to learn, widely accessible and can be performed at the bedside of hemodynamically unstable patients or those with high ventilator support, where shifting to a computerized tomography (CT) room involves substantial risk. Bedside lung ultrasound in emergency protocol has been formulated to guide intensivists and emergency physicians to enable a systematic approach in the diagnosis of various lung pathologies using ultrasound within a time of 3 min. LUS also provides a guide to fluid challenge requirements in acutely ill patients. It is a modality of immense help to physicians in the treatment and management of acutely ill patients who need emergent care. For the preparation of this review article, Medline search was done to assess previous review articles on LUS and the current clinical trials comparing the efficacy of LUS to other modalities of pulmonary imaging like chest radiograph and CT thorax. Review articles comparing the sensitivity and specificity of bedside LUS to CT thorax were also searched to establish the utility of LUS in diagnosing various lung pathologies.
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Who should use a face mask during COVID-19 pandemic? An evidence-based review Highly accessed article p. 149
Suresh K Sharma, Ravi Kant
DOI:10.4103/ijrc.ijrc_27_20  
There is a lot of confusion about who should use face mask during this serious COVID-19 pandemic. Irrational use of masks has caused serious shortage of mask availability for frontline health-care workers, who really require it. Therefore, the authors have carried out this comprehensive evidence-based review to guide policy-makers for the rational use of the face mask in this crisis. Social distancing, meticulous hand hygiene and respiratory etiquettes are more important in curbing the COVID-19 infection transmission rather than use of face mask alone but people may use multilayer cloth face covering especially in the areas of significant community-based transmission of SARS-CoV-2. Frontline health-care workers essentially require the full set of personal protective equipment, including gown, gloves, goggles or face shields, shoe covers, and mask, preferably N95 or equivalent respirator when exposed to aerosols. In case, N95 or equivalent equipment is not available, and then, surgical mask can also protect them adequately during non-aerosol generating procedures, provided meticulous hand hygiene is practiced.
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Theophylline and leukotriene modifiers: Is there any compelling role in COPD? p. 153
Abhijeet Singh, Rajendra Prasad, Nikhil Gupta
DOI:10.4103/ijrc.ijrc_65_19  
Chronic obstructive pulmonary disease (COPD) is considered to be an emerging global public health problem. Inhaled therapies are first-line maintenance treatment for COPD, whereas oral drug therapies are used as second or third line maintenance treatment. Oral drugs have modest bronchodilatory as well as anti-inflammatory activities but have lower potency as compared to inhaled therapies. Oral drug therapy can play an important role with several advantages that include distinctive pharmacologic mechanisms of action, prompt availability, ease of administration without the challenges of proper inhalational drug deposition in airways of lung and cost-effectiveness. Theophyllines and leukotriene modifiers are frequently prescribed oral drug therapies worldwide. Although evidence remains weak regarding the exact role of theophyllines in COPD, they are still used alone or as an add-on agent to inhaled therapies but at the expense of narrow therapeutic index leading to dose-dependent toxicities. Leukotriene modifiers are currently prescribed as add-on agents to inhaled therapies in moderate-to-severe asthma. However, the role of leukotriene modifiers in COPD is not very convincing with limited evidence. Overall, there is not any compelling evidence on the utility of theophyllines and leukotriene modifiers in the management of COPD.
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Management of chronic obstructive pulmonary disease: Insights into patient profile – Use of inhaled corticosteroids/long-acting β2-Agonists or long-acting β2-agonists/long-acting muscarinic antagonists p. 162
Nevin Kishore, Saibal Moitra, Mrinal Sircar
DOI:10.4103/ijrc.ijrc_56_19  
The noncommunicable chronic obstructive pulmonary disease (COPD) ranks among the top five leading causes of death worldwide. It is a preventable chronic disease that has become a major public health concern globally, as well as in India. To improve the pharmacotherapeutic management of COPD and to increase awareness about the prevalence of the disease, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has updated recommendations for the disease, based on the current clinical evidence. The present GOLD guideline endorses inhaled corticosteroids (ICS) combined with long-acting β2-agonists (LABA) for a subgroup of patients. The article is an attempt to clearly define patient profiles that stand to benefit from ICS/LABA, LABA/long-acting muscarinic antagonists (LAMA), and ICS/LABA/LAMA combination therapy based on current clinical evidence. The discussion is presented under the following headings: (i) disease burden worldwide, as well as in India; (ii) clinical symptoms and diagnosis of disease; (iii) risk factors leading to the development of disease; (iv) pharmacotherapeutic agents for COPD; (v) current updated recommendations from GOLD guidelines; (vi) subgroup of patients who can benefit from various combinations of therapeutic agents; and (vii) comparative analysis of clinical studies on various GOLD guideline-suggested combination therapies.
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Inhalational injury management: From intubation to nebulized heparin p. 171
Nissar Shaikh, Abdul Gafoor M. Tharayil, Ranjan Mathias, Raju Vegesna, Jimmy Thomas, Marcus Lance
DOI:10.4103/ijrc.ijrc_8_20  
Inhalational injury is common during fire accidents. Upper airway injury occurs due to heat, whereas the lower airway injury is caused by chemical irritation. It causes local damage to the upper, lower airway, and lung parenchyma leading to erythema, bronchorrhea, edema, airway obstruction, and surfactant loss. Plasma leakage occurs due to a storm of pro-inflammatory markers and vascular leak, with fibrin deposition, leading to formation of airway cast and debris increasing the risk of airway obstruction. Systemic complications occur due to anoxia, carbon monoxide, and hydrogen cyanide poisoning. An inhalational injury should be suspected in patients with a history of exposure to flames and in those who are entrapped in a closed compartment during the fire. Facial burns, singed facial or nasal hair, stridor, and carbonaceous sputum should raise suspicion of high index of inhalational injury. Severity of inhalational injury can be graded using 133 Xenon (radioisotope) study, bronchoscopy, computerized tomography findings, or virtual endoscopy. In the management of inhalational injury, keeping airway patent and secured is of vital importance. According to the advanced trauma life support principles, these patients should be intubated early, but as per the recent literature, it may not be necessary to intubate all inhalation injury patients. Adjuvant therapy includes bronchodilators, mucolytics, and beta-agonists. Nebulized heparin is found to be useful as it breaks and prevents new clot formations in the airway without any systemic anticoagulant effects. Inhalational injury is an independent risk factor for increase in mortality in burn patients.
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ORIGINAL ARTICLES Top

An insight into bronchiectasis: Causes, clinical features, and treatment practices p. 178
Laxmi Devi, Rajiv Garg, Ankit Kumar, R.A.S. Kushwaha, Santosh Kumar
DOI:10.4103/ijrc.ijrc_4_20  
Introduction: Bronchiectasis is a common, progressive respiratory disease characterized by irreversibly dilated, damaged, and thickened bronchi. It is present as a clinical syndrome of chronic cough, sputum production, and recurrent lower respiratory tract infections. The diagnosis depends on a degree of strong clinical and radiological suspicion. The aim of study was to give an overview of the causes, clinical features, and treatment practices of patients with bronchiectasis. Patients and Methods: This was a single-center, hospital-based, prospective, observational study in nonrandomized consecutive patients. All suspected cases were investigated by performing relevant blood, sputum, and radiological investigations. Diagnosis and etiology were confirmed with High Resolution Computed Tomography and clinical evaluation. Diagnosed cases were prescribed treatment as per the standard guidelines and followed up for a year. Results: Symptom wise, all enrolled patients had cough with expectoration, 71% complained of dyspnea, 41% had hemoptysis, and 35% had chest pain. Etiologically, bronchiectasis was postinfective in 46.5% and posttubercular in 34.9% cases. Antibiotics and pulmonary rehabilitation were taken by 28% of the cases, and antibiotics, pulmonary rehabilitation, and bronchodilators were taken by 25%. Conclusions: Although considered an “orphan” disease, bronchiectasis still accounts for a considerable number of patients, especially in a tertiary care center. When suspected on the chest radiograph, it can be confirmed on the high-resolution computed tomography thorax. Postinfective causes such as pneumonia and tuberculosis appear to be the predominant etiology leading to bronchiectasis. Treatment strategies are mainly symptomatic, and the disease can be controlled with appropriate antibiotics and pulmonary rehabilitation.
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Prevalence of allergic rhinitis among adult bronchial asthmatic patients of North Karnataka, India p. 183
Keertivardhan D Kulkarni, Tanuja P Pattankar
DOI:10.4103/ijrc.ijrc_43_19  
Background: Asthma and allergic rhinitis (AR) are diverse manifestations of allergic diseases of the airway. An individual may have either or both diseases. It is not known if the co-occurrence of these two diseases can take control of asthma difficult in our population. Objectives: The objective was to determine the prevalence of AR in patients with bronchial asthma and to understand its effect on control of asthma among adults. Methodology: This was a cross-sectional study done at a medical college in North Karnataka. Eighty confirmed patients of bronchial asthma attending the outpatient department of the respiratory department were enrolled as cases in the study, and another 80 patients without bronchial asthma were enrolled as controls. A structured questionnaire of the score for AR and asthma control test was used in this study. AR was clinically diagnosed by the presence of either watery rhinorrhea, nasal blockage, or excessive bout of sneezing, itching of eye, ear, nose, or throat. Results: Among the asthmatics, 74% had accompanying AR, while only 21% of controls had AR. About 64% of cases with AR had uncontrolled asthma, whereas 27% of cases without AR had uncontrolled asthma. Conclusion: The prevalence of AR among adult patients with bronchial asthma is high, and the co-occurrence of AR is associated with poor asthma control
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Need for pulmonary screening in rheumatoid arthritis patients: An observational study p. 186
B Ganga, Subin Ahamed, G Gokul Krishna
DOI:10.4103/ijrc.ijrc_55_19  
Background: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by articular and extra-articular involvement. The extra-articular involvement in RA is primarily manifested in pulmonary system characterized with pleurisy, airway diseases, nodular formations, and interstitial involvement. Aim: The aim was to assess the need of pulmonary screening in RA. Patients and Methods: A cross-sectional observational study was conducted on 122 patients who presented with respiratory difficulties and suspected RA. Initial screening for pulmonary involvement was done with physical assessment and pulmonary function tests (PFTs) followed with high-resolution computerized tomography (HRCT) scan. Health-related quality of life was assessed with pre–post 6-min walk test (6MWT) followed with dyspnea assessment and pulse oximetry. Results: Of the 122 patients screened, 33 were diagnosed with RA. The mean age was 40–50 years, was more common in women, and PFT showed both restrictive and obstructive pattern. Review of HRCT pattern of all patients showed nonspecific interstitial pneumonia pattern as the most common finding. Patients had desaturation after 6MWT and worsening of dyspnea. Conclusion: The degree of pulmonary involvement in RA is related to the duration of the disease. Clinical assessment, PFT, and 6MWT used in combination are cost-effective tools in early detection. HRCT provides a better understanding of the pattern of pulmonary involvement in RA.
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A cross-sectional study for the evaluation of pulmonary embolism in unexplained dyspnea in acute exacerbation of chronic obstructive pulmonary disease p. 191
Anshika Jindal, Yogendra Singh Rathore, Vinod Joshi, Shubhra Jain, Narendra Khippal
DOI:10.4103/ijrc.ijrc_1_20  
Context: An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common condition seen in emergency. Clinical conditions which mimic AECOPD are congestive heart failure, pneumonia, pneumothorax, pleural effusion, and pulmonary embolism (PE). Early recognition of PE can be difficult due to overlap in clinical symptoms of AECOPD. This should prompt clinicians to enhance PE suspicion in AECOPD patients of unknown origin. Aims: The aim of the study was to assess the prevalence of PE in unexplained acute exacerbation of COPD, severity, duration of hospital admission, and to explore factors associated with co-existing disease. Patients and Methods: This was a hospital-based cross-sectional study, conducted at a tertiary care center of Rajasthan. One hundred and ten cases of AECOPD of unknown origin hospitalized in the department of pulmonary medicine during the study period were included after conforming to the inclusion and exclusion criteria. Results: In our study, the prevalence of PE in unexplained AE-COPD was 18%. Clinically, chest pain and hemoptysis were present in 80% and 12% of the patients with PE, compared with 49% and 5% of the patients without PE, respectively. The mean duration of hospital stay of AECOPD patients without PE was 2.69 ± 1.08 compared to 6.65 ± 1.56 in PE, which is a highly statistically significant difference (P < 0.001) in the study population. Conclusion: Clinicians should be alert toward the presence of PE in patients with unexplained AECOPD, especially when chest pain, hemoptysis, disproportionate tachycardia, and signs of right ventricular failure are present and no clear infectious origin can be identified.
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Desaturation on 6-min walk test: A test with high negative predictive value to rule out pulmonary hypertension in interstitial lung diseases p. 196
Vishwas Gupta, Swapnil Manaji Thorve, Pralhad Prabhakar Prabhudesai
DOI:10.4103/ijrc.ijrc_63_19  
Introduction: Pulmonary hypertension (PH) is one of the major complications of interstitial lung diseases (ILDs) that contributes to increased morbidity and mortality. Predicting and promptly diagnosing PH may improve the outcome in these patients. We evaluated the utility of 6-min walk test (6MWT) to predict PH earlier in the course of ILDs. Patients and Methods: A total of 113 patients diagnosed with ILD as per standard investigation protocols were included in this observational study. Patients were evaluated with 6MWT, pulmonary function tests, and two-dimensional echocardiogram. Patients having mean pulmonary arterial pressure >25 mmHg were labeled as PH, and 4% drop from pretest oxygen saturation was considered as significant desaturation. Results: It was observed that 40% of patients with desaturation on 6MWT had PH. None of the patients without significant desaturation had PH. Conclusion: Desaturation on 6MWT is not an early predictor of PH, which is one of the major complications of ILDs. However, it has a high negative predictive value in the prediction of PH in patients with ILD.
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Factors predicting outcomes of tracheostomy decannulation among the patients at a tertiary care centre at Riyadh, Saudi Arabia - A retrospective, observational study p. 199
Prachi Tambur, Farhan Alenezi, Winnie Philip, Sulochana Kumari, Lojain Ebrahim Almaniei, Maram Srwi Asiri, Amjad Mubarak Alshahrani
DOI:10.4103/ijrc.ijrc_7_20  
Introduction: Decannulation, the removal of the tracheostomy tube, is an essential procedure that a treating team must consider for all tracheostomized patients. There is a lack of evidence available regarding the factors that are associated with the outcomes of the decannulation process. The study aims to detect the outcome of decannulation, describe factors associated with failed decannulation and to describe the decannulation practice in adult patients at a tertiary hospital in Riyadh, Saudi Arabia. Methodology: We performed a retrospective descriptive study for 210 tracheostomized patients aged 18 and above from January 2016 to December 2017. Demographic data, tracheostomy data, and decannulation process data were collected and entered in Microsoft Excel and exported to SPSS for the analysis. Results: Among 210 patients, the majority of tracheostomies were done at the bedside (55.2%). A total of 186 (88.6%) patients were successfully decannulated within 6 months. Obesity, comorbidity, and Glasgow Coma Scale (GCS) during admission were not associated with failure. Faster decannulation (73.5%) was found in those patients ventilated <7 days. Among 41 patients who underwent failed trials of decannulation, the most common reason of failure was desaturation in 19 patients (46.3%). Six patients of them had a combination of desaturation with other factors such as secretions, low GCS, and vocal cord paralysis. Conclusion: Successful decannulation within 7 days is related to the presence of full tracheostomy team. However, having a protocol approach will be more helpful. The study showed favorable outcome for young patients and those who had an early tracheostomy in the intensive care unit.
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Assessment of inhalational techniques and their common errors in bronchial asthma patients coming to tertiary hospital of South Gujarat p. 204
Shivani Dalal, Khyati Shamaliya, Anas Patni
DOI:10.4103/ijrc.ijrc_15_20  
Objective: The objective was to assess the inhalational techniques and its common errors in bronchial asthma patients. Methodology: This cross-sectional study was conducted from July 2019 to September 2019. All known asthmatic patients on inhaler therapy attending the Respiratory medicine outpatient department and who met the inclusion criteria were enrolled in the study. All participants were assessed using a pre-designed questionnaire and a standard checklist that was filled using the interview-based method. Data were entered into MS Excel 2010 and analyzed using Epi Info 7.0 and SPSS 16.0. Appropriate frequencies, percentages, and proportions were calculated, and necessary statistical tests were applied. Results: Of 113 participants, 72 (63.71%) were women and 41 (36.28%) were men. Moreover, 92 patients (81.41%) used dry powder inhalers (DPIs) and 26 patients (23%) used metered-dose inhalers (MDIs). Among these, 73 (64.60%) patients showed incorrect technique in which 57 (50.44%) patients were on DPI and 16 (14.15%) patients on MDI. Among 54 (47.78%) patients with poor clinical control, 46 (40.70%) patients with incorrect technique had partially controlled or uncontrolled asthma. Conclusion: Despite the availability of proper guidelines, incorrect inhaler technique remains the main causative factor for poor asthma control and compliance.
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Interstitial pneumonia with autoimmune features – An observational study in a tertiary care institute from South India p. 209
Ravi Charan Avala, Narendra Kumar Narahari, Anu Kapoor, Bhaskar Kakarla, Rajasekhar Varma, Paramjyothi Kruparao Gongati
DOI:10.4103/ijrc.ijrc_13_20  
Background: Often, patients with idiopathic interstitial pneumonia (IIP) have certain specific clinical features to suggest an autoimmune disease but do not justify the current rheumatologic classification systems to fit into a diagnosis of connective tissue disease (CTD)-associated IIP. There is a great paucity of clinical, serological, and radiological data of these patients from India. Aim: The aim was to study the clinicoradiological and autoantibody profile in patients with interstitial pneumonia with autoimmune features (IPAF). Methodology: It was a prospective, observational study conducted in a tertiary care center between December 2015 and December 2016. A total of 30 patients who satisfied the criteria for IPAF according to the American Thoracic Society/European Respiratory Society research were included in the study. Results: All 30 patients satisfied IPAF criteria, but they did not meet the immunological criteria for CTD. Majority of them were female (86.67%) and nonsmokers. The mean age was 52.5 ± 14.5 years. The most common clinical symptom was inflammatory arthritis in 20 (66.67%) patients, followed by Raynaud's phenomenon in 5 (16%) patients. Nonspecific interstitial pneumonia was the most common radiological pattern seen in 20 (66.67%) patients, while antinuclear antibody (1:320) was the most common autoantibody positive in 18 (60.0%) patients, followed by rheumatoid arthritis factor in 15 (50%) patients. Conclusions: High female predominance along with distinct imaging, histologic and serological characteristic features are seen in patients with IPAF as compared to those with IIP. Further studies in patients with IPAF are needed to understand the natural history and its management.
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Hospital oxygen supply: A survey of disaster preparedness of Indian hospitals p. 216
Cherish Paul, John Paul, Akhil Babu
DOI:10.4103/ijrc.ijrc_31_20  
Background: Uninterrupted oxygen supply is an essential hospital facility. Careful planning is needed to prevent major mishaps in case of failure. We undertook a survey to assess vulnerability of oxygen supply systems to disasters. Methodology: Hospitals in South India were stratified and randomized based on their bed strength. A structured telephonic interview was done to the managers of engineering departments in these hospitals. The questionnaire included type of oxygen source, location, changeover mechanism, and alarm systems. Results: Of the 30 hospitals randomized, adequate information was obtained from 25 hospitals. The primary source of the supply was cylinder manifolds in 48%, liquid oxygen in 40%, and concentrators in 12% hospitals. A reserve source of oxygen supply was available in 64% hospitals; 44% with cylinders, and 20% with liquid oxygen. Only 52% of the hospitals had a reserve supply in a different location from the primary. Changing the source of supply was manual in 44% of hospitals and 20% had an automatic change over system installed. There were effective zonal and central alarms in only 12% of hospitals. Conclusion: Most of the hospitals rely on a single pipeline from a single location inviting mishaps during the disasters. Contingency planning to reduce the risk of an uninterrupted supply should involve automatic changeover systems to a backup source with physically separated feed lines. Primary, secondary, and reserve supply could involve the use of liquid oxygen, oxygen concentrators, or cylinder manifold systems in various combinations depending on the size of hospital, proximity to a liquid oxygen plant and risk.
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CASE REPORTS Top

Awake self-proning in a nonintubated COVID patient: A case report from a tertiary care COVID hospital in Eastern India p. 221
Sunil Kumar Jena, Sujit Kumar Pradhan, Saswat Subhankar, CM Rao
DOI:10.4103/ijrc.ijrc_51_20  
The year 2020 has witnessed the novel coronavirus disease 2019 (COVID-19) outbreaks occurring in almost all countries of the world, causing the WHO to declare it a pandemic. The disease mainly causes pneumonia and subsequently may deteriorate to hypoxemic respiratory failure. In India, a hugely populated country, there will be always a threat for depletion of ventilator and other critical care resources if the disease spreads widely. As per the previous literature, proning is known to be a proven method to improve oxygenation in ventilated acute respiratory distress syndrome patients. Here, we would like to report an adult COVID-19 patient, who presented with hypoxemia and managed with awake self-proning.
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Absent lung slide but no pneumothorax: A case of spontaneous diaphragmatic hernia presenting with dyspnea p. 224
Margi Tusharbhai Bhatt, R Sunil, R Shwethapriya
DOI:10.4103/ijrc.ijrc_5_20  
Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies. The diagnosis may be delayed if a patient presents with respiratory symptoms without any history of trauma. In this report, we present a case who was admitted to the emergency department with shortness of breath, nausea, vomiting lasting for 3 h, and was diagnosed initially with pneumothorax based on chest X-ray and ultrasonography thorax findings. An intercostal drain was placed in the emergency ward. This was later diagnosed to have spontaneous diaphragmatic rupture. The patient was operated upon, and the defect was repaired. Diaphragmatic rupture should be considered along with other possible diagnoses, especially in the presence of suspicious appearances on the chest radiography in a patient with respiratory and/or gastrointestinal symptoms. The utility of bedside ultrasound in the diagnosis of spontaneous diaphragmatic hernia is yet unproven. The only treatment is surgical along with supportive care.
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A case of mumps presenting as severe pneumonia with acute respiratory distress syndrome p. 227
Neeraj Sharma, Aditya Joshi, M Krishna Kumar, Neelabh Nayan
DOI:10.4103/ijrc.ijrc_51_19  
The mumps virus causes an acute viral syndrome which is generally a self-limiting condition. It primarily affects the children. The majority of cases present with parotid swelling which is usually followed by complete recovery. Symptomatic infection is typically more severe in adults than in children. Encephalitis, meningitis, and orchitis are the most common serious complications of mumps. Pneumonia is an extremely rare and unusual complication of mumps. In this case report, the patient was an adult who presented with a short history of fever, unilateral parotid swelling, cough, and worsening breathlessness. On evaluation, he was diagnosed as a case of mumps complicated with severe pneumonia. The patient later developed a severe acute respiratory distress syndrome, which was managed successfully by prone ventilation, recruitment maneuvers, lung-protective ventilation (high positive end-expiratory pressure and low tidal volume), and other supportive measures.
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Primary nasal tuberculosis p. 230
Manoj Kumar Pandey, Poornima Mishra, Anil Gupta
DOI:10.4103/ijrc.ijrc_44_19  
Tuberculosis can involve any part of body. Tubercular bacteria rarely involve nose as a primary site for infection. This site of involvement of Mycobacterium tuberculosis (MTB) is rarer even in endemic country like India. Here we are presenting a case of primary nasal TB.
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Foregut duplication cyst mimicking pulmonary tuberculosis: A rare presentation p. 233
Poonam Sherwani, Devasenathipathy Kandasamy, Priyanka Naranje, Devender Yadav
DOI:10.4103/ijrc.ijrc_21_20  
Foregut duplication cyst is a rare congenital anomaly in children. Most of the children are asymptomatic and are diagnosed incidentally when evaluated for other problems. Complications include infection, rupture, and malignant transformation. Here, we present a case of complicated foregut duplication cyst in a 10-year-old female which mimicked tubercular spondylitis on imaging.
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Retrieval of aspirated teeth in an adult polytrauma patient using pediatric flexible fiberoptic bronchoscopy allied with endoscopic rat tooth alligator jaw grasping forceps p. 236
Ali Al Bshabshe, Amer Hassan Assiri, Nasser Mohammed Alwadai, Omprakash Palanivel
DOI:10.4103/ijrc.ijrc_10_20  
Foreign body (FB) aspiration in maxillofacial injuries is a life-threatening event. A long-time interval between the aspiration and retrieval results in the formation of granulation tissue and mucosal inflammation around the FB, which could restrict the visual field of bronchoscopy and its retrieval. In addition, it can affect the lung structure with fatal complications. Herein, we present a case of unique FB retrieval (2 joined crown teeth – measuring 19 mm) within 8 h following aspiration in a 24-year-old male polytrauma victim. Further, we discuss our successful modified retrieval technique accordingly without resulting in any complications.
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LETTERS TO EDITOR Top

Bilateral chylothorax: An uncommon complication of unilateral central venous catheter placement p. 240
Shalendra Singh, Venigalla Sri Krishna, Saurabh Sud, Deepak Dwivedi
DOI:10.4103/ijrc.ijrc_2_20  
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A syringe-actuated metered-dose inhaler for patients with tracheal intubation: A comment p. 242
Jay Prakash, Mohd Saif Khan, Ramesh Kumar Kharwar
DOI:10.4103/ijrc.ijrc_16_20  
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Beware from inadvertent fitting of the disposable syringe p. 243
Jay Prakash, Mohd Saif Khan, Ramesh Kumar Kharwar, Anivesh Mishra
DOI:10.4103/ijrc.ijrc_23_20  
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Aftermath of COVID-19: Adieu stethoscope? p. 245
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DOI:10.4103/ijrc.ijrc_29_20  
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DOI:10.4103/ijrc.ijrc_37_20  
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