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   Table of Contents - Current issue
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January-April 2021
Volume 10 | Issue 1
Page Nos. 1-166

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EDITORIAL  

The hidden cost of COVID-19! p. 1
Madhuragauri Shevade, Anitha Nileshwar
DOI:10.4103/ijrc.ijrc_132_20  
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REVIEW ARTICLES Top

Potential complications and sequelae of SARS-CoV-2 infection p. 4
Jyoti Nath Modi, Amrita Ghosh, Ranabir Pal, Rajashekar Mohan, Luis Rafael Moscote-Salazar, Santosh Wakode, Amit Agrawal
DOI:10.4103/ijrc.ijrc_100_20  
COVID-19 disease caused by the SARS-CoV-2 virus affects almost all the organ systems of the body leading to multisystemic morbidities and typical complications hitherto unheard of in seasonal “flu” or SARS-CoV-1 epidemic. Acute life-threatening complications range from unabated pneumonia and respiratory failure to “cytokine release syndrome” or “cytokine storm,” cardiovascular and cerebrovascular morbidities leading to multiorgan failure, followed by death. The prepathogenesis, pathogenesis, and the clinico-demographic characteristics of SARS-CoV-2 infection have shown a wide variation across different populations, geographical regions, race, and ethnicities. While there are some commonalities, there continues to be a lack of consensus on several aspects of this infection such as its natural history, infectivity, transmission, and its mutagenic strains. Further, newer aspects of the disease have continued to emerge with passing time since its first appearance in December 2019 in Wuhan, China. The initial case descriptions varied from asymptomatic to mild illness requiring minimal monitoring and support to severe COVID-19 disease requiring admission to intensive care facilities and a higher morbidity and mortality. Only subsequently it was recognized that even after the clinical recovery from illness, the infection may persist for a longer time, with continuing damage to some organ systems and sequelae that compromise the quality of life. These have been called the long-term complications or “chronic COVID” infection, and they may be noted even months after recovery from the acute form of disease. While thus far the global efforts have been rightfully directed at combating the acute illness in the pandemic and maximizing recovery, it is possible that we may soon be faced with the challenge of a “secondary pandemic” with a significant burden of chronic COVID and sequelae. This will be a strain on the palliative care, rehabilitative care, and domiciliary care network essentially supported by the primary health-care providers or first-contact physicians worldwide. This approach is in alignment with an emphasis that the WHO placed on the third clinical outcome indicator “functioning” in addition to the two indicators “cure” and “death.” The present review discusses the pathophysiology, clinical aspects, and implications of long-term effects of SARS-CoV-2 infection. It is expected to help in sensitizing the health-care workers and policymakers for preparing adequately and timely for dealing with these effects.
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Covid-19-related vs Covid-19-unrelated Acute respiratory distress syndrome - key differences p. 10
Harish Mallapura Maheshwarappa, Moumita Chakraborty, Amal TJ Joseph, Sibiya Poonely Chacko, BM Ramya
DOI:10.4103/ijrc.ijrc_106_20  
A recent global pandemic has resulted from the outbreak of coronavirus disease (COVID-19) infection. One of the key clinical features of this infection is the presence of severe acute respiratory syndrome coronavirus 2 virus. The port of entry for COVID-19 is the lung and if the infection worsens, it progresses to acute respiratory distress syndrome (ARDS). As the pandemic continue to surge, findings from studies and case reports suggest that the ARDS caused by COVID-19 might have different characteristics than what we refer to as non-COVID-19 (Typical) ARDS. By applying the differences in clinical features between COVID-19-related ARDS and typical ARDS, clinicians may develop appropriate therapeutic protocols to treat these patients effectively. Our review article intends to elucidate these differences in clinical features based on time of onset, radiological specifications, lung mechanics, phenotypical characters, inflammatory mediator response, and nature of coagulation abnormality.
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Dry powder inhalers: Particle size and patient-satisfaction p. 14
SK Jindal, KK Pandey, PP Bose
DOI:10.4103/ijrc.ijrc_57_19  
Inhalational route is the cornerstone for drug delivery in asthma. Dry powder inhalers efficiently deliver drug particles to lungs depending on patients' breath actuation and without using propellants. Drug delivery in lungs is dependent primarily on particle size distribution of the formulation. Several studies have proved that drug particles 1–3 μm in size provide optimum efficacy with minimum adverse events. Particles >3 μm are deposited in the oropharynx and those <1 μm are exhaled. However, these fine particles might not be felt in the mouth due to which patients may feel that appropriate amount of drug was not dispensed. This perception may negatively influence patient satisfaction and confidence on the device. The patient education on the absence of mouthfeel is thus essential. Treating physicians should provide optimum patient counseling and education addressing the importance of particle size for desired clinical effects.
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Vaccination in adults with chronic lung disease – Revisiting 2019 immunization guidelines p. 19
Rohit Vadala, Isabella Princess, Pratap Upadhya
DOI:10.4103/ijrc.ijrc_33_20  
Effective immunization programs have always resulted in successful eradication of targeted infectious diseases. Apart from childhood immunization, adult immunization is required for two major reasons: 1. failure of primary immunization, 2. to boost waning effect of childhood vaccines. Adult immunization gained its importance in the recent years with detailed recommendations laid down by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). In most countries, adult vaccination guidelines fall back on the WHO and CDC adult immunization schedules. With evolving number of chronic lung disease patients, it is mandatory to educate and encourage patients on available options for vaccination. A successful immunoprophylaxis given to high-risk group individuals will definitely improve their quality of life.
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Lung transplantation for idiopathic pulmonary fibrosis: A narrative review p. 24
Nazia Mehfooz, Farhana Siraj, Parvaiz A Koul
DOI:10.4103/ijrc.ijrc_18_20  
Idiopathic pulmonary fibrosis (IPF) is a debilitating and progressive lung disease without an identifiable cause. It is the most common form of interstitial pneumonias. The prognosis is worst in this disease with median survival of just 2–3 years after diagnosis without a lung transplant. Currently, there are no proven medical therapies to cure IPF. Pharmacological agents such as nintedanib and pirfenidone retard the progression of the disease to an extent but without any survival benefit. The only therapeutic option for IPF is lung transplantation with proven survival benefit. The major concern with lung transplantation is waiting time mortality. Lung allocation score was introduced in 2005 to reduce this mortality. Both single- and double-lung transplantations are used worldwide for IPF. Bilateral lung transplantation has been seen to have better survival rates in some studies, but there are no randomized trials which favor this recent trend. The posttransplant survival is lower than seen in other indications for lung transplantation. Posttransplant follow-up should be vigilant to detect complications as early as possible and treat them accordingly.
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ORIGINAL ARTICLES Top

Neurocognitive profile and depression in obstructive sleep apnea p. 30
Rajasekhar Varma, Narendra Kumar Narahari, Paramjyothi Kruparao Gongati, Afshan Jabeen Shaik, Bhaskar Kakarla, Padmaja Gaddamanugu, Ravi Charan Avala
DOI:10.4103/ijrc.ijrc_84_20  
Background: Neurocognitive decline and depression are the most common unaddressed but noticeable adverse consequences linked with obstructive sleep apnea (OSA) which can affect work performance, social functioning, and quality of life. It is significant to explore both cognition and mood disorders in OSA, as there is adequate evidence in the literature supporting the efficacy of continuous positive airway pressure (CPAP) in the management. Aims and Objectives: The aim was to assess the neurocognitive profile and depression in patients with OSA in our center. Patients and Methods: This was a cross-sectional observational study conducted in a tertiary care center between January 2017 and January 2018. A total of 92 patients with an established diagnosis of OSA (by polysomnography) were included in the study. All patients were given questionnaires for the assessment of neurocognitive function and depression scoring. Results: Out of 92 OSA patients, 29 (31.5%) had normal cognition, 43 (46.7%) had mild cognitive impairment (CI), and 20 (21.7%) had major CI. Out of twenty patients with major CI, major attention deficit was observed in 17 (85%), memory impairment in 16 (80%), verbal fluency was affected in 13 (65%), deficit in language skills was observed in 7 (35%), and visuospatial abilities were affected in 17 patients (85%). Out of 92 OSA patients, 21 (22.8%) had depression and 71.4% of them were females. Conclusions: OSA is an independent risk factor for both depression and neurocognitive decline. It is highly recommended that patients with OSA should be screened for both, so as to provide better clinical outcomes.
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Clinical, biochemical, therapeutic, and complication strategy of high-altitude pulmonary edema: Update from Western Himalayas p. 35
Krishan Singh, Santosh Kumar Singh, Vani Singh, Ajai Kumar Tentu, AK Naik, Nidhi Singh, Gaurav Joshii
DOI:10.4103/ijrc.ijrc_77_20  
Introduction: People traveling to high altitudes (HAs) for work or pleasure are increasing day by day. The rewards of such travel are generally at the risk of developing of acute altitude illnesses and/or worsening of underlying medical problems. The present study was undertaken in a hospital at 11,500 feet to get updated information on the wide clinical spectrum of patients of high-altitude pulmonary edema (HAPE). Patients and Methods: The study was carried out at a general hospital located at 11,500 feet. The total number of study participants was 151. They were divided into two groups: those who were entering HA for the first time were 17 participants and those who had spent several months at HA 134 patients. All patients in the second group had been completely acclimatized before going down to sea level. The Lake Louis Criteria were taken as the basis for the diagnosis of HAPE. Results: Pulmonary edema was the most common serious illness seen at HA. Majority of the patients presented at 72–96 h after induction to HA. The common symptoms were breathlessness, cough, and headache at rest. In addition, all patients complained to a varying extent of one or more of the following symptoms: dyspnea, cough, fever, chest pain, dizziness, etc., The majority of the patients showed leukocytosis. Pneumonitis may be a predisposing factor or develop secondary to pulmonary edema. Conclusion: Pulmonary edema was the most common serious illness seen at HA. The common symptoms were breathlessness, cough, and headache at rest. The understanding of HAPE has changed since its emergence in the field of diagnosis, pathophysiology, complications, and therapeutic modalities.
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Clinicoradiopathological features among mediastinal masses p. 41
R Sridhar, R Narasimhan, L Sundararajan, Raj B Singh
DOI:10.4103/ijrc.ijrc_48_20  
Background: The mediastinum is a place where various benign and malignant diseases usually manifest as mass and present as interesting diagnostic challenge. The purpose of this study was to describe clinical features, radiological, and pathological information of mediastinal masses to help have an organized approach to diagnosis of mediastinal masses. Patients and Methods: This was a prospective, descriptive cross-sectional study conducted over a period of 1 year at our hospital after obtaining ethical committee clearance. Patients with mediastinal masses fulfilling the inclusion criteria were enrolled in the study. Patient's clinical history, radiological features, techniques used to obtain specimens, and cyto-histopathology results from data collected in our total study population were analyzed. Results: A total of 73 patients with mediastinal masses were included. Thirty-three of them (45.2%) were malignant and 32 (43.8%) were nonmalignant masses. The masses were commonly located in the middle compartment (n = 42 [57.5%]), followed by anterior compartment (20 [27.4%]), posterior compartment (8 [11%]), and multicompartment (3 [4.1%]). Among middle mediastinal masses, infectious masses were 14 (33.3%), followed by 11 (26.2%) malignant masses. Anterior mediastinal masses were predominantly malignant in nature (90%). Nature of mass was inconclusive in eight (11%) patients. Conclusion: Clinical history, anatomical position, and imaging characteristics allow the correct diagnosis in many cases when it is combined with histopathology. The newer endoscopic techniques such as endoscopic ultrasound-guided fine-needle aspiration or biopsy are generally preferred in view of lesser complications and ease compared to more invasive surgical procedures for mediastinal mass evaluation.
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Clinico-radiological profile of silicosis patients presenting at a tertiary care centre of Haryana, India p. 47
Ruchi Arora Sachdeva, Sachet Dawar, Sunil Nagar, Deepali Parashar, Sandeep Sachdeva
DOI:10.4103/ijrc.ijrc_60_19  
Objectives: The aim of this study was to study the patients working in stone crushing units presenting with respiratory symptoms for occupational lung disease, silicosis. Patients and Methods: Over a span of 2 years, 176 consecutive new stone crusher workers diagnosed with silicosis were clinically evaluated, including radiological investigations, spirometry, and sputum for acid-fast bacilli. Results: All patients were male manual workers with average age and duration of stone dust exposure of 42.9 years and 20.11 years, respectively; 57 (32.3%) gave a history of smoking; 33% of patients had taken anti-tubercular treatment in the past. However, sputum of none of the patients was found positive for acid-fast bacilli. Only 4 (2.2%) patients mentioned the use of gloves and masks during work shifts. Breathlessness was the most common symptom (92%), followed by cough (61.9%), chest pain (48.3%), expectoration (6.8%), hemoptysis (5.7%), and wheezing (2.8%). Chest radiograms showed opacities-small (up to 10 mm, 57.95%) and large (>10 mm, 17.04%); pleural thickening (97.2%), diaphragmatic thickening (97.2%), and calcifications (71%) etc., Predominant lesions on high-resolution computerized tomography scan of the thorax were mediastinal lymphadenopathy (94.3%), round opacities (90.3%) followed by parenchymal bands (59.1%) and linear opacities (52.8%). On spirometry, 71 (40.3%) patients had findings within the normal limits. Conclusion: It is reiterated that silicosis has severe debilitating effects on the health of subjects, and the situation warrants continuous monitoring.
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Clinicoradiological profile of patients with hydropneumothorax: A prospective study of a hospital population in Northern India p. 53
Saurabh Kumar Singh, Pratibha Yadav, Bhupendra Jatav, Kamlesh Kumar Tiwari
DOI:10.4103/ijrc.ijrc_87_20  
Background: Hydropneumothorax is defined as the presence of air and liquid (pus, fluid, or blood) in the pleural cavity, and it carries significant morbidity. Aim: The aim of the study was to explore the demographic and clinical-radiological characteristics of patients with hydropneumothorax. Patients and Methods: This study was conducted in the tertiary care center of northern India. Patients diagnosed with hydropneumothorax between January 2017 and December 2019 were included in the study. Sociodemographic characteristics, causes, symptoms and signs, and X-ray findings were collected and analyzed prospectively. Results: Fifty-two patients with hydropneumothorax were included in the study, 39 of whom were male. The mean age of patients was 34.17 ± 11.6 years. Dyspnea and cough were the most common findings in 50 (96.2%) and 49 (94.2%) patients, respectively. Fever was seen in 47 (90.3%), chest pain in 48 (92.3%), weight loss and loss of appetite in 30 (57.7%) patients, and hemoptysis in 11 (21.2%) patients. Cavitation was the most common chest X-ray finding seen in 34 (65.4%) cases. Tuberculosis (61.5%) was the most common cause of hydropneumothorax. For the management of hydropneumothorax, an underwater intercostal tube drain (ICD) was inserted in all the patients. The mean duration of intercostal drainage (ICD) in 51 patients was 21.3 ± 10.6 days. Conclusion: Patients of hydropneumothorax presenting with symptoms of respiratory distress required a prolonged period of chest tube drainage and usually showed a good response to the treatment.
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Endobronchial biopsies in the diagnosis of lung lesions – A study of 204 consecutive cases from a single center in Southern India p. 57
Nirmala Jyothi, Monalisa Hui, Shantveer G Uppin, N Narendra Kumar, K Bhaskar, GK Paramjyothi
DOI:10.4103/ijrc.ijrc_62_20  
Objectives: The objective of this study is to evaluate the diagnostic yield of endobronchial biopsy in various neoplastic and nonneoplastic lung lesions. Patients and Methods: A total number of 204 consecutive cases of fiberoptic bronchoscopic-guided endobronchial biopsies was analyzed. The bronchial wash (BW) samples collected simultaneously during the biopsy were correlated with final histopathology diagnosis. Results: The bronchoscopic findings mainly included endobronchial mass, increased mucosal vascularity, and mucosal irregularities. Of the 184 adequate biopsy samples, 32.3% were neoplastic, 20.5% nonneoplastic, and remaining 41.3% revealed normal histology. The nonneoplastic lesions included mainly nonspecific inflammation, granulomatous inflammation followed by few cases of squamous metaplasia, one case each of tracheobronchopathia osteochondroplastica, mycobacterium spindle cell pseudotumor, and cytomegalovirus infection. Among the malignant tumors, adenocarcinoma (ADC) was the most common followed by squamous cell carcinoma (SQCC) and non-small cell carcinoma-not otherwise specified. On immunohistochemistry, Napsin-A showed better sensitivity than thyroid transcription factor-1 for ADC. P40 was found to be most sensitive and specific markers for SQCC. Neuroendocrine tumors included seven small cell carcinoma and three carcinoids. Both chromogranin and synaptophysin were found to be equally sensitive neuroendocrine markers. The bronchoscopically normal airways mostly revealed normal histology with few showing mild nonspecific inflammation. On the contrary, all except one case of neoplasm had mass lesions on bronchoscopy. Conclusion: EBB provides sufficient tissue for morphological and immunohistochemical characterization of malignant lesions. BW cytology has poor concordance with EBB in the diagnosis of malignancies with nearly 70% cases being false negative.
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Respiratory morbidities in preterm neonates during the first year of life: A prospective observational study p. 70
Jenisha Jain, Lakshmi Venugopal, R Shanmughsundaram
DOI:10.4103/ijrc.ijrc_91_20  
Background: Infants born preterm develop numerous short- and long-term respiratory morbidities. However, there are scanty data available from India. Aims: The study was conducted to determine the incidence of hospitalization due to respiratory morbidities during the 1st year of life in preterm neonates (<37 completed weeks). The secondary aim was to determine the impact of respiratory morbidity on growth and need for nebulization. Patients and Methods: This prospective study was conducted in a level III neonatal intensive care unit. Data regarding maternal and neonatal history and examination were collected in the study proforma. Follow-up was done at predetermined intervals, and details of subsequent outpatient and inpatient treatments were recorded. Statistical analysis – Chi-square test/Fisher's exact test, unpaired t-test, and multivariate logistic regression were used for statistical analysis. P < 0.05 was considered as statistically significant. Results: Three hundred and forty-four infants (192 – male and 121 – inborn) were included. Fifty-eight (16.8%) infants were readmitted – 84% bronchiolitis, 12% pneumonia, and 27.5% as wheeze-associated lower respiratory tract infection. On multivariate analysis, growth status at birth, presence of hemodynamically significant patent ductus arteriosus (PDA), lower socioeconomic status (SES), and lack of exclusive breastfeeding were associated with risk of readmission. 12.2% (42/344) of the admitted preterm neonates needed nebulization with bronchodilators during follow-up. Growth was hampered in those requiring readmissions. Conclusion: 16.8% of the preterm neonates were admitted for respiratory morbidities at 1-year follow-up. Small for gestational age, presence of hemodynamically significant PDA needing medical closure, lack of exclusive breastfeeding for 6 months, and lower SES were risk factors for respiratory morbidity in infancy.
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Bronchoscopy safety box and its utility as a barrier in spread of COVID-19 infection Highly accessed article p. 76
Sameer A Arbat, Sweta Raja Chourasia
DOI:10.4103/ijrc.ijrc_102_20  
Introduction: The COVID-19 pandemic has infected millions with a high mortality rate. Thousands of frontline health-care workers (HCWs) have been infected with SARS-CoV-2. Protecting HCWs is important. Aim: We sought to develop an innovative barrier to prevent COVID-19 virus transmission while performing bronchoscopy and endotracheal intubation. Settings and Design: We have designed and developed a barrier called bronchoscopy safety box (BSB). Materials and Methods: BSB is made up of acrylic and polyvinyl chloride (PVC) sheets. We have designed two prototypes of BSBs, namely Prototype 1 and Prototype 2. We performed bronchoscopy procedures and intubation procedures with BSBs. Advantages and limitations were noted and analyzed. Results: The advantages of BSB include the additional presence of the bronchoscopy aperture and an assistant aperture. All the apertures are covered by PVC sheets or hand gloves, thus minimizing risk of aerosol coming out of these apertures. The presence of PVC sheet fixed at the patient's end restricts the amount of aerosol coming out while the presence of a negative suction port is important in reducing the aerosol content inside the BSB. The BSB is a multi-utility box which can be used by clinicians for endotracheal intubation or bronchoscopy as the need arises. The BSB can be effectively used for the treatment of suspected as well as confirmed COVID-19 patients. Conclusions: We conclude that the BSB is a reusable, multipurpose aerosol safety barrier which can be utilized for multiple procedures of bronchoscopy as well as intubation to help protect HCWs against COVID-19.
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Comparison of intubating conditions using “spray-as-you-go” technique versus transtracheal instillation of lignocaine for airway topical anesthesia during awake nasal fiberoptic intubation p. 82
Priyanka G Kini, G Umesh, KN Prasad, K Gurudas Kini
DOI:10.4103/ijrc.ijrc_127_20  
Introduction: Awake fiberoptic intubation (AFOI) is the gold standard for the management of recognized difficult airway. Good airway anesthesia along with sedation is necessary to ensure patient comfort. Aim: The aim of the study was to evaluate topical lignocaine administered by “spray-as-you-go” versus transtracheal injection technique on intubating conditions during AFOI. Patients and Methods: After obtaining written informed consent, 36 patients were randomly allocated to one of two groups: Group T – transtracheal technique and Group S – Spray-as-you-go technique. All patients were sedated with intravenous dexmedetomidine infusion titrated to a Ramsay Sedation Score of 2–3 during AFOI. All patients received oral gargle and nasal packing with lignocaine 2%. Patients in Group T received 2 mL lignocaine 2% intratracheally just prior to beginning fiberscopy. Patients in Group S received 2 mL lignocaine 2% spray over the vocal cords and another 2 mL below the vocal cords during fiberscopy. Tracheal intubation was then performed. Primary outcome measure was a composite score of patient comfort. Secondary measures were intubation and fiberscopy time, adverse effects, and postoperative patient evaluation. Results: The demographic data were comparable. A composite score of <10 was considered optimal, 10–15 as acceptable, and >15 unacceptable. Significantly more patients in Group T had optimal composite score compared to Group S. There were no differences between the two groups as regards postintubation score, ease of intubation, and postoperative survey. Conclusion: During awake nasal fiberoptic intubation, in comparison with spray-as-you-go technique, the transtracheal instillation of lignocaine improves patient tolerance and comfort during tracheal intubation and provides better patient satisfaction.
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Knowledge, attitude, and practices toward the COVID-19 pandemic among the indian general population: A cross-sectional survey p. 88
Lakshmi Venkata Simhachalam Kutikuppala, A N Syamasundara Kiran, Tarun Kumar Suvvari
DOI:10.4103/ijrc.ijrc_73_20  
Background: Coronavirus disease 2019 (COVID-19) disease is highly infectious, and fever, dry cough, fatigue, myalgia, and dyspnea are the main clinical symptoms of the disease. There is a necessity to understand the public's awareness of COVID-19 to facilitate the outbreak management of COVID-19 in India. Collection of knowledge, attitude, and practice (KAP) information regarding outbreaks has long been useful in apprising prevention, control, and mitigation measures during such outbreaks. Objectives: The study objective was to evaluate knowledge levels, prevailing attitudes, and practices among the general population of India about the COVID-19 pandemic and to rule out barriers concerned with practicing risk reduction behaviors. Methodology: A cross-sectional study was conducted online among the general population of India during the lockdown period. The KAP toward COVID-19/severe acute respiratory syndrome-coronavirus-2 infection and prevention were assessed by using a self-administered questionnaire with 32 questions. The KAP assessment was carried out by assigning scores to the variables. SPSS version 24.0 and Chi-square test were used for statistical analysis. Results: A total of 1292 people had participated in the survey, and their mean age was 29.43 years. Overall, 81% of the participants had good knowledge, 77% of the participants had a positive attitude, and 83.5% of the participants were following good practices. Nearly 94% of the participants are confident that India can overcome COVID-19, and 97.7% of the participants wore masks when they went out. Conclusion: Health education campaigns and awareness events targeting the general population can enhance knowledge and attitudes of the people to the pandemic and potentiate better practices in facing the crisis.
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Knowledge, confidence, and perception of respiratory therapists as frontliners in managing COVID-19 cases – A questionnaire survey p. 93
Aathira Rajan, Madhura Reddy, Pratibha Todur, Saumy Johnson
DOI:10.4103/ijrc.ijrc_122_20  
Background: The deadly outbreak of coronavirus disease 2019 (COVID-19) has imposed many challenges to health-care professionals (HCPs). The knowledge, confidence in performing clinical skills, and psychological impact have been studied among various HCP. Respiratory therapists (RTs) are the frontliners in handling critically ill COVID-19 victims. Although being an integral part, there are no studies on RTs in COVID-19. Hence, we aim to study the knowledge, confidence, and perception of RTs in managing COVID-19. Subjects and Methods: A cross-sectional, questionnaire-based survey conducted among RTs in India. The present study was conducted from July 15, 2020, to August 1, 2020. Descriptive analysis was used to describe demographics, mean knowledge, confidence levels, perception, and psychological impact on RTs. Results: A total of 68 RTs responded with a response rate of 70.8%. Of them, 60% (41) had good knowledge, 96% (65) had higher confidence in performing required clinical skills, 98.5% (67) had a perception that RTs plays an essential role in COVID-19 care, and 98.5% (67) had a negative psychological impact. Reliability of the questionnaire was found to be in acceptable range. Conclusions: This study found that RTs in general had good knowledge and higher level confidence in performing procedure related to COVID-19. RTs perceive that the role of RT in COVID-19 is important.
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CASE SERIES Top

Utility of awake prone positioning with low-dose systemic corticosteroids in coronavirus disease 2019 acute respiratory distress syndrome patients: A case series p. 100
Vishal Shanbhag, Souvik Chaudhuri, NR Arjun, Nitin Gupta, Shashikiran Umakanth, Kavitha Saravu
DOI:10.4103/ijrc.ijrc_66_20  
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2, novel enveloped RNA beta-coronavirus. The clinical manifestations vary from no symptoms to fever, cough, respiratory distress, pneumonia, and adult respiratory distress syndrome (ARDS) or uncommonly diarrhea. Typically, the disease has viremic phase, pulmonary phase, and severe host inflammatory phase. Prompt interventions in the first two phases such as awake prone positioning and administration of low-dose corticosteroids can prevent the onset of the third phase of the deadly disease. Awake prone positioning and systemic corticosteroids are simple interventions, which can prevent the requirement of mechanical ventilation and also lead to reduction in the inflammatory response and disease severity. We report a case series of six patients who diagnosed with COVID-19 ARDS and were benefitted by awake prone positioning sessions and low-dose systemic corticosteroid therapy.
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Outcome of superselective bronchial artery embolization in patients with massive hemoptysis p. 107
Jijo Oommen Roy, Sridevi Rajeeve, Anna Mathew
DOI:10.4103/ijrc.ijrc_35_20  
Hemoptysis, the coughing out of blood, is a fear-provoking symptom with possible life-threatening implications such as hypotensive shock, asphyxia and, myocardial stunning. The severity of hemoptysis can range from streaky episodes to massive episodes (> 500 ml/day or > 150 ml/hour). The etiology of hemoptysis varies from lower respiratory causes such as tuberculosis, lung cancer, bronchiectasis, lung abscess, and pulmonary thromboembolism. The usual line of management is detailed history, imaging studies such as chest X-ray and CT thorax and excluding drugs affecting bleeding and clotting. Treating the underlying cause and including procoagulants usually helps to control moderate bleeding. Swift and effective management is important, especially in life-threatening cases as patients deteriorate fast. Bronchial artery embolization is indicated when conventional medical management fails and the patient is hemodynamically unstable to undergo emergency lobe/lung resection surgeries. We report our experience with four patients who presented to us with massive hemoptysis in whom superselective bronchial artery embolization (SBAE) was carried out successfully with gel-foam and coil. These patients were meticulously followed up for possible complications for one year.
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CASE REPORTS Top

Anti-CD6 humanized monoclonal antibody itolizumab, halts disease progression and severity of acute respiratory distress syndrome in COVID-19 disease: A case study p. 112
Hemant P Thacker, Amit Dhekane, Nivedita Wadhwa, Shalaka Patil
DOI:10.4103/ijrc.ijrc_78_20  
In COVID-19 patients, cytokine release syndrome plays a critical role in disease progression. Itolizumab inhibits T-cell proliferation and differentiation, thereby modulating imminent cytokine storm. Here, we report a case of a 44-year-old male patient with confirmed COVID-19 and oxygen saturation (SpO2) of 88% on room air. A chest X-ray revealed dense opacification. High levels of inflammatory markers such as C-reactive protein (CRP) and ferritin were observed. The patient's SpO2 decreased to 87% on day 4 despite the best supportive care. Itolizumab was then administered at 1.6 mg/kg along with high flow oxygen. The patient's SpO2 values improved to 95% and 97% on 4th- and 5th-day postinfusion, respectively. CRP and ferritin levels decreased by 85.96% and 24.48%, respectively, along with radiological improvement. The patient was discharged on the 7th day postinfusion in a clinically stable condition. This is the first report of an anti-CD6 humanized monoclonal antibody, itolizumab, given to a patient with moderate-to-severe COVID-19 disease that showed a reduction in hyperinflammation, leading to clinical and radiological improvement.
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Spontaneous pneumothorax during the recovery phase of coronavirus disease-19 Pneumonia p. 116
Begum Oktem, Tarık Yağcı, Fatih Uzer
DOI:10.4103/ijrc.ijrc_72_20  
There is not enough information about short- and long-term complications of coronavirus disease 2019 (COVID-19) infection, following treatment. Pneumothorax due to barotrauma after adult respiratory distress syndrome has been observed in some viral infections. However, spontaneous pneumothorax occurring after treatment is uncommon. We report a case of chronic obstructive pulmonary disease (COPD), who presented to the emergency department with pneumothorax 1 month after receiving treatment for COVID-19 infection. The patient had shortness of breath starting 3 weeks after discharge. He had a history of hospitalization due to a COPD attack within the past year. He was diagnosed as pneumothorax with radiological imaging.
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Pyothorax following kerosene ingestion: A severe complication of kerosene poisoning p. 120
Anindya Chattopadhyay, Pankaj Halder, Somak Krishna Biswas, Niladri Mukherjee
DOI:10.4103/ijrc.ijrc_40_20  
Pyopneumothorax following kerosene aspiration is not rare in children, but seldom requires surgical intervention. We report a case of kerosene poisoning in a 25-month-old girl where aspiration pneumonitis progressed to pyothorax in spite of supportive medical therapy. Thoracoscopic drainage was done to prevent on-going lung damage and sepsis.
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Cavitating pulmonary infarct in absence of any co-existing cardiopulmonary disease p. 123
Sunil Kumar, Jyoti Kumari
DOI:10.4103/ijrc.ijrc_11_20  
In a patient who had no co-existing cardiopulmonary disease, pulmonary infarction (PI) and cavitation in the infarct is a rare phenomenon. Here, we are reporting such a rare case of cavitating pulmonary infarct who presented with pneumonia. A 65-year-old woman presented with typical infective symptoms such as high-grade fever, dyspnea, and pleuritic chest pain. Her vitals were within normal limits except hyperthermia. Chest X-ray showed right basal consolidation at admission that showed cavitation on the 5th-day chest radiograph. Computerized tomogram of the thorax showed cavitated pulmonary infarct and bilateral pulmonary thromboembolism. All microbiological investigations were negative. She denied having any previous cardiac problem and her current echocardiogram was also unremarkable. This case represents the transition phase of PI and cavitation that was misdiagnosed as a community-acquired pneumonia due to similar clinical and radiological features. PI can present as cavitating pneumonia, even in the absence of any co-existing cardiopulmonary disease.
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Lung cancer coexisting with pulmonary tuberculosis: A rare case report p. 126
Amanpreet Kaur, NC Kajal, Amit Goyal
DOI:10.4103/ijrc.ijrc_22_20  
Lung cancer and tuberculosis (TB) are common causes of morbidity and mortality in the world. TB is a serious public health problem in developing countries including India, bearing the highest burden. Lung cancer is also increasing everywhere in the globe with India having the highest mortality due to lung cancer in males. Both diseases coexist producing a diagnostic dilemma. The simultaneous or sequential presentation of pulmonary TB and lung cancer within the same patient has been reported in various case series and case–control studies, but the association between them is still controversial. TB is an important risk factor for developing carcinoma lung. The dormant bacilli may activate due to disturbed defense mechanisms. Pulmonary cancer mortality was also higher in patients developing TB, simultaneously or during treatment courses, than in those without. The diagnosis may be delayed and the patient's survival may be decreased?. Pulmonary TB coexisting with lung cancer can mask the underlying disorder resulting in delay in diagnosis and management of cancer patients. Here, we present a rare and interesting case of a 52-year-old male who was diagnosed as a case of microbiologically confirmed pulmonary TB and squamous cell lung carcinoma at the same time.
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Intercostal artery aneurysm in a child with disseminated tuberculosis and coexistent takayasu arteritis: A rare case report p. 129
Poonam Sherwani, Mriganki Choudhary, Yash Shrivastava, Pankaj Sharma
DOI:10.4103/ijrc.ijrc_41_20  
Intercostal (IC) artery aneurysm due to underlying tuberculosis (TB) is very rare in adults and even rarer in children, and very few cases have been reported so far. The underlying mechanism is due to erosion of the arterial wall due to adjacent inflammation such as empyema, pericarditis, or cavitatory lesion. Aortic pseudoaneurysm or Rasmussen aneurysm is common in pulmonary TB. However, asymptomatic and incidentally detected pseudoaneurysm of the right IC artery in a child with disseminated TB is infrequent. Although the association of TB and Takayasu arteritis (TA) is well known, the association of IC artery aneurysm due to underlying TB along with TA has not been reported previously.
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Pulmonary neurofibromatosis with bilateral bronchiectasis: A rare thoracic manifestation p. 132
Manoj Kumar Pandey, Jyoti Bajpai, Surya Kant, Hemant Kumar, Poornima Mishra
DOI:10.4103/ijrc.ijrc_45_20  
Neurofibromatosis type 1 (NF1), also known as von Recklinghausen's disease, is an autosomal dominant genetic disorder. The incidence of NF is 1 in 3000 individuals. Approximately one-half of the cases are familial, while the remaining occur sporadically due to germ cell mutations. The clinical manifestation of NF1 may include a café-au-lait macule usually 5–15 mm in diameter, multiple neurofibromas, axillary or inguinal freckling, optic glioma, Lisch nodules, and a distinctive bony lesion. Although very rare, pulmonary manifestation in neurofibromatosis can occur in the form of mediastinal neurofibromas, pleural neurofibromas, tracheobronchial neurofibroma, interstitial lung disease, bullous lung disease, and cystic lung disease. Here, we present a rare case of pulmonary neurofibroma with bronchiectasis.
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Primary pulmonary synovial sarcoma: How to expect the unexpected? p. 136
Mayank Yadav, Sumit Pratap Singh, Mohd Azam Haseen, Braj Mohan Singh, Noor Ahmad Lari, Mohammed Haneef Beg
DOI:10.4103/ijrc.ijrc_49_20  
Primary pulmonary synovial sarcoma (PPSS) is a rare and aggressive malignancy with a presentation similar to that of lung carcinoma. We present an 18-year-old male who presented with complaints of chest pain, cough, and hemoptysis. Physical examination and blood parameters were normal. Imaging studies revealed a large, well-defined, round homogeneous mass in the left lower lobe. His fine-needle aspiration cytology was suggestive of a round cell tumor. The patient was operated under general anesthesia through left posterolateral thoracotomy. The tumor was removed en masse and sent for histopathological examination. His histopathology and immunohistochemistry suggested PPSS of biphasic variety.
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Bronchiolitis obliterans organizing pneumonia in a young healthy female patient p. 139
Zubair Ahmed, Naveed Ahmed, Waheed Ahmad Baig
DOI:10.4103/ijrc.ijrc_83_20  
One of the idiopathic respiratory tract inflammation is cryptogenic organizing pneumonia (COP). Most patients are symptomatic for <2 months and have a clinical presentation that resembles community-acquired pneumonia. The diagnosis of COP requires histopathologic identification of a predominant pattern of organizing pneumonia and the exclusion of any possible cause. In the patient described herein with interstitial pulmonary disease, the diagnosis of COP was achieved by fiberoptic bronchoscopy. The pathologic findings disclosed bronchioles, alveolar ducts, and alveoli infiltrated with mononuclear cells. The lumina were obliterated with fibroblasts and loose granulation tissue. Corticosteroid treatment resulted in significant improvement. In our patient, the only significant finding was profound Type I respiratory failure without significant raised inflammatory markers. Transbronchial biopsy was a key in making a diagnosis of our patient, as the patient was unwell to undergo video-assisted thoracoscopic surgery.
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Intralobar sequestration of right lung: An unusual presentation p. 143
Manoj Kumar Pandey, Hemant Kumar, Preeti Gupta
DOI:10.4103/ijrc.ijrc_61_20  
Bronchopulmonary sequestration (BPS) is a rare congenital disorder of the lung. It consists of a nonfunctioning lung tissue that is not normally connected with the tracheobronchial tree and receives its blood supply from systemic circulation. The presentation of sequestration is variable, ranging from asymptomatic to more severe symptoms such as massive hemoptysis, resulting in increased mortality and morbidity. Although BPS commonly involves left lower airway, here we report the case of a 17-year-old female who presented with recurrent hemoptysis and was eventually diagnosed with pulmonary sequestration in the right lower lobe, an unusual presentation of intralobar sequestration.
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Lobar agenesis of the lung in a newborn: A rare case report p. 146
Pradyumna Pan, Ritika Pan
DOI:10.4103/ijrc.ijrc_38_20  
Lobar agenesis (LA) of the lung is a very uncommon congenital anomaly. Typically, the presentation is with respiratory symptoms, but the onset is highly variable. LA may be an isolated defect, but is often associated with congenital VACTERL anomalies. Here, we describe a neonate with agenesis of the middle and upper lobes of the right lung.
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Hot cross bun sign: A case report of multiple system atrophy presenting predominantly as respiratory insufficiency p. 148
Margiben Tusharbhai Bhatt, R Sunil
DOI:10.4103/ijrc.ijrc_60_20  
Multiple system atrophy (MSA) was a multisystem disorder usually associated with Parkinsonism, MSA-p subtype or with cerebellar ataxia, and MSA-c subtype. Respiratory insufficiency can be a part of the clinical manifestation of multiple-system atrophy. It can sometimes present as primary respiratory failure, mild motor function disturbance, or autonomic dysfunction. In this article, we present a case of a 60-year-old lady who was admitted to the intensive care unit with fever and shortness of breath of 3 days duration with an initial working diagnosis of community-acquired pneumonia requiring invasive mechanical ventilation. She had a history of daytime sleepiness and gait disturbance. A thorough neurological evaluation was done to ascertain the cause of difficulty in weaning her off the ventilator. Magnetic resonance imaging of the brain revealed atrophy of bilateral superior cerebellar peduncles and pons with the “hot cross bun sign” suggestive of multiple system atrophy. Thus, a prompt neurological examination and work-up, including brain imaging, are mandated in dealing with such cases of difficult to wean patients.
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A rare case of late presentation of dasatinib-induced cardiopulmonary toxicity p. 152
Harshit Khurana, Vijoy Kumar Jha, Ajay Handa, Debasish Mahapatra
DOI:10.4103/ijrc.ijrc_65_20  
Tyrosine kinase inhibitors (TKI) (imatinib, dasatinib, and nilotinib) are used for the treatment and long-term control of chronic myeloid leukemia (CML). TKIs rarely cause systemic side effects with atypical presentations, and these must be borne in mind while prescribing these drugs over a prolonged period. Dasatinib-induced cardiopulmonary toxicity should be suspected in patients presenting with new-onset cardiac or pulmonary symptoms, with features of congestive cardiac failure and pulmonary infiltrates. We report a rare presentation of simultaneous occurrence of pleural effusion, interstitial pneumonitis, pulmonary hypertension, and heart failure in a CML patient on dasatinib for >6 years, which was successfully treated with discontinuation of the drug and oral steroids.
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SHORT COMMUNICATIONS Top

Containment of coronavirus disease-2019 pandemic in India: Need to adopt a concerted and multisectoral response p. 156
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_24_20  
The coronavirus disease-2019 (COVID-19) pandemic has threatened the progress made in the field of the health sector across the globe. From the Indian perspective, we have become the third most affected nation across the globe and the trends of the novel infection continues to worsen further. All these estimates are a clear marker of the fact that we have not been up to the mark in terms of both preparedness activities as well as the public health response to the infection. Amidst all these developments, there is an indispensable need that we have to divert our all our resources and adopt a multi-sectoral response for the effective containment of the infection with the active and concerted support of all the stakeholders. In conclusion, the COVID-19 cases in India has been increasing on an alarming note and it is the need of the hour to continue to improve our outbreak readiness and emergency response. Further, we cannot defeat the COVID-19 until we all are together in the battle against the novel infection and continue to support the Government in all their planned strategies.
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Coronavirus disease 2019 pandemic and tuberculosis control: Possibilities of joint action p. 158
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_123_20  
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LETTERS TO EDITOR Top

COVID-19 infection: Use of face masks in children in community settings p. 160
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_99_20  
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Bullous reaction on tuberculin skin test p. 162
Ramakant Dixit, Ashok Singh Charan, JS Broca
DOI:10.4103/ijrc.ijrc_39_20  
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The noninvasive ventilation helmet: Another vital tool for the new normal p. 164
Arjun Khanna, Ankit Kumar Sinha, Sachin Maheshwari, Kamal Kishore Pandey
DOI:10.4103/ijrc.ijrc_67_20  
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Limitations of ventilating multiple patients using single ventilator during the COVID-19 pandemic p. 165
Neeraj Kumar
DOI:10.4103/ijrc.ijrc_69_20  
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ORIGINAL ARTICLES Top

Comparative study of demographic profile, mortality, risk factors, and bacteriological profile of respiratory isolates from ventilated patients: Ventilator-associated event versus nonventilator-associated event cases  
Abha Sharma, Madhusmita Das, Bibhabati Mishra, Poonam Sood Loomba
DOI:10.4103/ijrc.ijrc_19_20  
Introduction: Ventilator-associated pneumonia (VAP) rate has long been considered a quality indicator (QI) in intensive care units (ICUs) for mechanically ventilated patients. However, ever since the Centers for Disease Control and Prevention (CDC) redefined VAP as ventilator-associated events (VAEs), its validity as a tool for use in quality assurance needs to be assessed. Aim: The aim of the study was to identify VAE rate in ICU, compare the demographic and respiratory isolate profile and mortality with non-VAE cases, and identify risk factors for VAE. Materials and Methods: All ICU patients on mechanical ventilation (MV) for >2 days were followed prospectively. VAE data were collected using a checklist obtained from the CDC website (the National Healthcare Surveillance Network VAE surveillance tool). The demographic profile, risk factors, and treatment for each patient were recorded in a proforma. VAE rates were estimated per 1000 ventilator-days. Results: The overall VAE rate was 38.1/1000 MV days. Among VAE subtypes, 18.7% were ventilator-associated condition (VAC), 43.7% were infection-related VAC (IVAC), and 37.5% were possible VAP (PVAP). Survival rate was 100% for patients with VAC alone, whereas only 14.2% and 16.6% of patients survived with IVAC and PVAP, respectively. No significant association was found between age, gender, mortality, bacterial isolate, and VAE cases. Depressed level of consciousness, immunosuppression, antibiotic use, and reintubation were significant risk factors associated with VAE cases (P = 0.0001). Conclusion: There is no significant difference observed between VAE and non-VAE cases regarding demographic profile, respiratory bacterial profile, and mortality. More research is required to establish the role of VAE as a QI for patient care in ICUs.
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