Aim and background: Inhaled corticosteroids (ICS) and bronchodilators remain the mainstay of therapeutic modalities available for the management of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the effectiveness, utility, and economic analysis of a three-drug treatment vs a two-drug treatment in COPD patients. Materials and methods: An observation was conducted at a superspecialty hospital in Hyderabad. Out of the 115 patients recruited from the inpatient and outpatient wards of the Pulmonology Department, 55 patients received triple therapy containing ICS, long-acting β-agonists (LABA), and long-acting muscarinic antagonists (LAMA), whereas 60 patients were treated with dual therapy comprising ICS/LABA. Cost-effectiveness was assessed based on forced expiratory volume in 1 second (FEV1) (FEV1% predicted), St George's respiratory questionnaire (SGRQ) scores, SGRQ responder ratio, COPD assessment test (CAT) scores, and incremental cost-effectiveness ratio (ICER). Results: Results signified the enhanced potency of three-drug treatment vs two-drug treatment as proven by the improvement in average difference from initial values in (1) FEV1% predicted value of 4.36 [95% confidence interval (CI) (2.9–5.82)], (2) SGRQ scores of −6.76 [95% CI (−2.14 to −11.38)], SGRQ responder ratio of 13.25 (3.72–47.24), CAT scores of −5.15 [95% CI (−9.87 to −0.43)] and ICER of 3522 [95% CI (14682 to −7638)]. Conclusion: Triple therapy comprising LABA, LAMA, and ICS can optimize lung function and improve clinical outcomes, leading to overall enhancement of well-being compared to LABA/ICS dual therapy in moderate to severe COPD patients. Clinical significance: Three-drug treatment comprising ICS/LABA/LAMA is an effective and cost-effective therapeutic approach for managing moderate and severe COPD compared to ICS/LABA dual therapy. This is evidenced by improvements in spirometry values (FEV1% predicted) and health-related quality of life (HRQoL).

Background and objectives: Obstructive sleep apnea (OSA) is being progressively encountered in clinical practice due to the mounting epidemic of obesity, owing to an upsurge in sedentary habits in rural and urban populations. Sleep-related disorders are a common cause of morbidity and can lead to wide range of potentially fatal health problems such as high blood pressure, obesity, hypercholesterolemia, diabetes, heart attacks, and depression. The current study was steered with the objective to estimate the prevalence of comorbidities in patients with OSA and to evaluate the association between comorbidities and severity of OSA. Materials and methods: Sixty patients with OSA were included in the current study, and the prevalence of comorbidities and their association with the severity of OSA were determined. Results: Out of 60 patients with OSA, 62% were males and 38% were females, and their mean apnea–hypopnea index (AHI) was 40.11 ± 25.78. Mild OSA was present in 15% of patients, moderate and severe OSA in 31.7 and 53.3%, respectively. Males had higher prevalence of severe OSA than females. The most prevalent comorbidities were obesity, which was seen in 70%, followed by hypertension in 63.3%, and depression in 56.7% of patients. Although these were more predominant in patients with severe OSA, the difference was not statistically significant. Conclusion: The present study concluded OSA as significant risk factor for the emergence of comorbidities. Hence, patients with symptoms suggestive of sleep apnea should be assessed and treated early because lack of awareness of the disease and its associated comorbidities may result in increased mortality.

Aims and background: India bears the brunt of both tuberculosis (TB) as well as diabetes patients globally, and either disease affects each other detrimentally, leading to increased morbidity and mortality; thereby, hampering the national and international policies and goals targeted in the control and prevention of these diseases. Hence, this study was done to determine the correlation between the sputum cartridge-based nucleic acid amplification test (CBNAAT) cycle threshold (Ct) values and glycosylated hemoglobin (HbA1c) levels at the point of diagnosing pulmonary tuberculosis (PTB). Materials and methods: This study, conducted over a span of 6 months, followed a cross-sectional design. Patients diagnosed with PTB, confirmed by sputum CBNAAT, were enrolled in the study after screening them with the inclusion and exclusion criteria. The sputum CBNAAT Ct values were noted, and the average of the five probes labeled as A, B, C, D, and E was utilized to quantify the bacilli, reported as the mean Ct value. Semi-quantitative mycobacterial load results were categorized as follows—high (Ct values <16), medium (Ct values 16–22), low (Ct values 22–28), or very low (Ct values >28). The HbA1c (glycated hemoglobin) levels of the patients were estimated from a venous blood sample. Results: Out of 136 study subjects, 61% were male participants with a mean age of 41 years. Among them, 23.5% (n = 32) were previously known diabetics. Additionally, 37.5% (n = 51) were newly detected diabetics based on HbA1c levels (cutoff 6.4) at the time of PTB diagnosis. Most patients had a low bacterial load (44.10%, n = 60). The high bacterial load group (26.5%, n = 36) had the lowest mean Ct value of 15.51, while the very low bacterial load group (8%, n = 8) had the highest mean Ct value of 31.47. The high bacterial load group also had the highest mean HbA1c level of 7.6, whereas the low bacterial load group had the lowest mean HbA1c level of 6.03. The Pearson correlation coefficient is −0.426, indicating a moderate negative correlation between the two variables. Conclusion: This study found a moderate negative correlation between sputum CBNAAT Ct values and HbA1c levels in patients with pulmonary TB. This suggests that as HbA1c levels increase, the bacillary load also increases, as indicated by decreasing Ct values, and vice versa. Clinical significance: According to our study, patients with poor glycemic control have a high bacterial load, predicting more severe disease. This finding may help guide treatment decisions and improve patient outcomes.

Introduction: Nonresolving pneumonia (NRP) or slowly resolving pneumonia is a major concern among clinicians. The definition and approach toward diagnosis and management are unclear. Herein, we conducted a prospective observational study to analyze the comorbidities, etiology, and mode of diagnosis of NRP at our center. Methodology: All subjects admitted with a diagnosis of NRP (who received at least 2 weeks of antimicrobial therapy without any clinical improvement) were enrolled in the study. Patients with poor general condition, hemodynamic instability, and uncooperative patients were excluded from the study. After noting clinical and demographic details, contrast-enhanced computed tomography (CT) scan was done for all patients. All subjects were assessed to undergo flexible bronchoscopy, image-guided sampling, surgical lung biopsy, or pleural fluid analysis based on the imaging findings on CT scan. The details of the mode of diagnosis and the yield of procedures were noted. Results: We included 102 subjects; an infective etiology was diagnosed in 64 (62.7%) of the cases and 38 (37.2%) were diagnosed to be of noninfective etiology. Among the infections, pulmonary tuberculosis [21 (20.6%)] and invasive fungal diseases [20 (19.5%)] were the most common diagnoses. Diabetes mellitus (57.8%) and recent COVID-19 (26.5%) were the common comorbid conditions predisposing to infection. Among the noninfectious etiology, pulmonary adenocarcinoma was the most common diagnosis seen in 14 (13.7%) cases. Flexible bronchoscopy was most instrumental in obtaining the diagnosis as seen in 71 (69.6%) cases, followed by image-guided biopsy in 17 (16.6%) and surgical lung biopsy in 7 (6.9%) patients. Overall yield of bronchoscopy in our study population is 77.2% (71/92) and image-guided sampling is 94.4% (17/18). The infectious group had shorter disease duration, more comorbid illnesses, mucopurulent secretions on bronchoscopy, and higher mortality at 1 month as compared to noninfectious group. After adjusting the covariates, the presence of fever [odds ratio (OR) 12.75; 95% confidence interval (CI), 2.74–59.26] and recent history of COVID-19 (OR 12.29; 95% CI, 1.43–105.6) were independently associated with infectious etiology. Conclusion: Infections, particularly tuberculosis and invasive fungal diseases, are the major causes of NRP. Diabetes mellitus is the predominant underlying comorbid illness, and recent infection with COVID-19 is an emerging risk factor for NRP. Flexible bronchoscopy and image-guided sampling, when used in rational approach, are helpful in establishing the diagnosis of NRP.

Introduction: A bronchoscope is important medical equipment used for bronchoscopy, a procedure that allows visualization of the upper and lower respiratory tract. Utilization of equipment is an important aspect for optimal patient handling and quality of care. The utilization coefficient (UC) gives a picture of the level of utilization of the equipment, which can be optimally utilized, overutilized, or underutilized. Materials and methods: A descriptive study was conducted in the respiratory medicine department of a tertiary care government teaching hospital for one month. The UC of the bronchoscope was calculated, taking into consideration the maximum hours it can be used in a day and the average hours it is used each day. Results: The average time the bronchoscope is used per day came out to be 4 hours, and the maximum time the bronchoscope can be used per day is 5 hours. The UC came out to be 80%, thus indicating optimal utilization of the bronchoscope. Conclusion: Results cater attention toward optimal utilization of equipment, which is an important factor frequently overlooked by management in the healthcare delivery system and can lead to losses by reducing yield.

Aim and background: A dysregulated immune response can produce acute lung injury and worsen clinical status of patient by causing organ dysfunction and severe pneumonia. Modulating the immune response can improve the outcome of illness and avoid treatment failures. Glucocorticoids are well-known natural inhibitors of inflammation that can be used as an adjunctive treatment; however, their use still remains controversial. Hence, we planned this study to look at the efficacy of steroids to reduce treatment failure among patients of severe community-acquired pneumonia. Materials and methods: This was a monocentric, single-blinded, randomized placebo-controlled trial, conducted in 55 patients admitted in Government Medical College and Hospital Sector 32, Chandigarh. Participants were enrolled after they met all inclusion and exclusion criteria over a period of 12 months from January 2023 till December 2023. After enrollment, they were randomized through a 1:1 ratio to receive injection methylprednisolone 0.5 mg/kg q12h for 5 days and placebo along with standard antibiotic therapy. Outcomes included assessment of treatment failure, length of hospital stay, and mortality. The collected data was analyzed with Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 26.0. Results: In this study of 55 patients, 50 were included for analysis, with 3 leaving against medical advice and 2 withdrawing consent. Both groups had a mean age over 50 years. Initial hemodynamic stability was faster in intervention group (p = 0.025), but delayed stability was similar in both. Mortality during hospitalization (28 vs 40%; p = 0.37) and length of stay (6 days vs 8 days; p = 0.815) showed no difference. Early (57 vs 73%; p = 0.256) and late clinical stability (p = 0.572) were not significantly different. Likewise, early treatment failure (44 vs 64%; p = 0.156) and late treatment failure (18.18 vs 26.3%; p = 0.705) did not differ. Overall, primary and secondary outcomes did not show any statistically significant distinctions. Conclusion: In treating severe pneumonia, the use of an adjuvant corticosteroid was found to be statistically equivalent to using an antibiotic alone in this trial. Nonetheless, the intervention group showed a discernible improvement in clinical indicators and a decrease in complications, duration of hospital stay, mortality, and treatment failure rate, all of which remained below the threshold of statistical significance.

Background and aim: Acute respiratory infection (ARI) is a leading cause of illness and mortality in children under five years old, especially in developing countries. The condition demands serious attention to reduce the disease burden. This study aimed to estimate the prevalence and associated factors of ARI in under-five children in rural Mysuru. Materials and methods: A community-based cross-sectional study was conducted over 6 months, from January to June 2023, among 400 children aged 6 months to 5 years in rural Mysuru. Data were collected using the interview method using a semi-structured interviewer-administered proforma. Results: The prevalence of ARI was reported to be 68.3%, with 65% of children experiencing at least one episode. Remarkably, children aged 1–3 years were most affected, with a prevalence of 45%. Notably, maternal education (31.2% with high school completion) and socioeconomic status (55.8% middle-class) played crucial roles. Environmental risk factors including ventilation, waste disposal, and water quality were implicated. Acute respiratory infection symptoms like fever, cough, and wheezing are statistically significant. Conclusion: Acute respiratory infection is a critical problem that requires attention and should be addressed among under-five children. The findings highlight a significant prevalence of ARI, affecting 68.3% of children in the age group of under 5 years. This study underscores the urgency of addressing ARI among young children, emphasizing the roles of maternal factors, environmental measures, breastfeeding, and immunization coverage in reducing ARI incidence.

Background: The role of inhaled nitric oxide (iNO) in managing acute respiratory distress syndrome COVID-19 related (C-ARDS) is debatable. The study aimed to analyze the effect of iNO administration in patients with persistent severe hypoxia and intensive care unit (ICU) mortality. Materials and methods: This retrospective study included 196 consecutive critically ill patients with C-ARDS admitted to ICU from 1 October 2020 to 31 October 2021. Results: Of these patients, 28% had received iNO. Twenty-four (44.4%) were responders. Kaplan–Meier plot shows mortality was higher in nonresponders (86.6 vs 25.0%). Nonresponse to iNo was the most important predictive value (p = 0.01). The receiver operating characteristic (ROC) curve for a percentage increase in partial pressure of oxygen (PaO₂) from baseline confirmed that it had a higher predictive value for inhospital survival. A value of 19% can predict the death event with a sensitivity of 81.8% and a specificity of 81.2%. Conclusion: Therefore, we propose to use iNO as a vasoreactivity test for prognostic stratification in patients with persistent severe hypoxia.

The coexistence of two conditions producing hypertrophic pulmonary osteoarthropathy (HPOA) is rare. In this case, the patient has pulmonary tuberculosis (PTB) and bronchogenic carcinoma, both of which can contribute to HPOA separately. A 69-year-old male presented with pain and swelling of wrist and fingers of both hands. The patient has a history of smoking. On examination, the patient had grade IV clubbing, minimal crepitations and wheeze on right side, and decreased breath sounds on left side. X-ray of the wrist showed new bone formation, and chest X-ray showed right upper lobe nonhomogeneous opacities and a left lower lobe mass lesion. Contrast-enhanced computed tomography (CECT) confirmed the same. Bronchial washing and sputum samples were sent for cartridge-based nucleic acid amplification test (CBNAAT) and came out as positive. Computed tomography (CT)-guided fine needle aspiration cytology (FNAC) from left lower lobe mass lesion revealed non-small cell lung carcinoma. It is quite rare for PTB and lung cancer to coexist. Though PTB rarely produces HPOA, this patient has HPOA with coexisting PTB and non-small cell lung carcinoma. It is more plausible to think HPOA is due to bronchogenic carcinoma than PTB.

We present a unique case of pulmonary nontuberculous mycobacteria (NTM) infection caused by Mycobacterium fortuitum in a patient who had previously undergone successful treatment for tuberculosis (TB). Despite the eradication of Mycobacterium tuberculosis, the patient developed respiratory symptoms and imaging findings indicative of NTM infection. This case report highlights the importance of considering NTM as a potential pathogen in immunocompetent post-TB individuals, emphasizing vigilance in diagnosis and management.

Pulmonary arteriovenous malformation (PAVM) is a rare abnormal connection between a pulmonary vein and a pulmonary artery, resulting in blood bypassing the capillary bed and causing right-to-left shunting. We aim to report a case of idiopathic PAVM managed with coil embolization to highlight this rare disease. A 15-year-old girl presented with a 2-year history of progressively worsening shortness of breath on exertion and intermittent self-limiting hemoptysis. She had cyanosis with an oxygen saturation of 86% on room air. No telangiectasia was seen. Chest X-ray revealed nonhomogeneous opacifications, most marked in the right lower zone. High-resolution computed tomography (HRCT) chest demonstrated centrilobular nodules, some with a branching pattern in the anterior segment of the right upper lobe and apical segments of both the right upper and lower lobes; interlobar and intralobar septal thickening along with a prominent bronchovascular bundle in the right upper and lower lobes. CT pulmonary angiography revealed multiple dilated and enlarged serpiginous vessels in the right lung; in the arterial phase, simultaneous opacification of arteries and veins demonstrated a connection between the pulmonary artery and veins, consistent with the diffuse type of PAVM. A diagnosis of idiopathic diffuse PAVM was made, and three sessions of coil embolization were performed over a period of 1 year. By the 12-month follow-up, she was stable and asymptomatic. PAVM is a rare occurrence, and early screening with prompt management is required to improve prognosis. Our patient, who presented with shortness of breath and hemoptysis, was diagnosed with idiopathic PAVM. She refused surgery and was managed with coil embolization, which resulted in marked improvement. The differential diagnosis of shortness of breath includes respiratory, cardiac, and hematological diseases. A high index of clinical suspicion is required to timely diagnose PAVM to reduce complications and morbidity. PAVM is best managed by a multidisciplinary team encompassing an internist, pulmonologist, interventional radiologist, and cardiothoracic surgeon.

Aspergillus fumigatus is an opportunistic fungus, found ubiquitously in the environment. A. fumigatus typically infects an immunocompromised host. This case report is about a 55-year-old immunocompetent woman who was initially treated with antibiotics after being diagnosed with a pulmonary infection. However, further investigations revealed fungal pneumonia due to A. fumigatus. The patient eventually responded to antifungal treatment, although adverse effects of the antifungals were observed. Despite its rarity, it is important to consider other differential diagnoses, such as fungal pneumonia, if the pneumonia does not respond to medical treatment, as well as the potential adverse effects of antifungals.

Introduction: Pleural effusion drainage in addition to antibiotics is used for the management of empyema and complex parapneumonic effusions (CPE). Fibrinolytics aid in drainage because fibrin adhesions create loculations in the pleural space. Although open thoracotomy and video-assisted thoracoscopic surgery (VATS) are the best therapeutic modalities, their widespread use is limited by operational risk and increased costs. Thus, intrapleural fibrinolytic therapy (IPFT) must be considered before more expensive and invasive techniques. Case description: We present a case of a 10-year-old girl who presented with fever, dry cough, and loss of appetite for 2 weeks along with breathlessness for 1 week. Her chest radiograph revealed left-sided massive pleural effusion for which left tube thoracostomy was done. It was a tubercular, exudative lymphocytic effusion. The patient was advised to undergo thoracic surgery in the form of VATS with thoracotomy for failed tube drainage. Instead of subjecting her to an expensive and major surgical procedure, she was subjected to IPFT with three doses of streptokinase. There was complete resolution of the loculated pleural effusion, and she was discharged after 3 days. Conclusion: Regardless of the etiology, IPFT is an affordable option for all kinds of loculated pleural collections and needs to be presented as the first choice, even when VATS is available.