Indian Journal of Respiratory Care

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2021 | April | Volume 10 | Issue S1

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Mathew Patteril, Anitha Shenoy, Kalpalatha Guntupalli, Vijaikumar Ratnavelu, Ramkumar Venkateswaran

When Air becomes Breath, Respiratory Therapy, an Inimitable Ally to Tackle COVID-19!

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:2] [Pages No:S1 - S2]

   DOI: 10.4103/ijrc.ijrc_6_21  |  Open Access | 



Shashikiran Umakanth, Prashanth Bhat, G Jagadeesha, Avinash Shetty

Bracing for the Pandemic: The Udupi-Manipal Experience

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S3 - S7]

Keywords: Bracing, COVID-19, dedicated hospital, infection control, pandemic, public-private partnership, training

   DOI: 10.4103/ijrc.ijrc_44_21  |  Open Access | 


COVID-19 was an unprecedented pandemic of our lifetime. Uncertainties were part of daily life and were the only certainty. Bracing for this pandemic at the level of a hospital was challenging. From infection control to patient management, from training healthcare workers to taking care of them, from public education to fighting fake news and misinformation, the pandemic presented with unique challenges and opportunities. This paper briefly discusses some of the important areas of focus and the experience of a dedicated COVID-19 hospital and the district during the pandemic.



Lakshmi Kumar, Keerthi Njerinjamkuzhi Satheesan, Meghalakshmi Alakkaparambil Ramachandran

Clinical Governance: Protecting the Health-Care Workers

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:7] [Pages No:S8 - S14]

Keywords: Clinical governance, health care workers, infection-control

   DOI: 10.4103/ijrc.ijrc_27_21  |  Open Access | 


Clinical governance in protecting the health-care worker (HCW) refers to measures taken by the organization in providing a safe environment for the HCW while maintaining excellence in the quality of care for the patients. In the wake of the SARS-CoV-2 virus pandemic, the key regulatory measures are taken by the infection control authority of the hospital. The Donabedian model suggests that this process is considered as structure, process, and outcome review measures. Structural changes include surveillance, screening measures, creation of outpatient clinics for COVID-suspected patients, and separate isolated bay for collection of the nasopharyngeal swab. Structural processes also include the creation of separate intensive care units (ICUs) and theaters for infected patients, negative pressure gradient in the operating room (OR), and sites where aerosol generation could occur. Creation of operational pathways such as intubation in the ICU and in the OR should be included in this. The process involves training of HCWs at various levels on the use of personal protective equipment (PPE). Provision of adequate numbers of PPE and cleaning solutions and establishing the diagnostic pathways such as the antigen test, reverse transcriptase-polymerase chain reaction, or nucleic acid amplification test are part of the processes set up by any organization. Outcome analysis involves rates of HCW infection from COVID care wards and ICU, patients testing positive at screening, and patients who may test positive after they undergo treatment at the facility. Long-term outcome measure may include mortality and length of hospital stay.



Muralidhar Kanchi, Moumita Chakraborthy, Amal T J Joseph, P Sibiya Poonely Chacko

Respiratory System-The Port of Entry of SARS-COV-2 with Special Reference to Aerosol Management

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:9] [Pages No:S15 - S23]

Keywords: Aerosol-generating procedure, barrier devices in COVID-19, pathophysiology of COVID-19, personal protective equipment, transmission of severe acute respiratory syndrome coronavirus-2

   DOI: 10.4103/ijrc.ijrc_131_20  |  Open Access | 


The outbreak of novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global pandemic of unprecedented proportions. Management of patients infected with COVID-19 has led to a great risk of hospital-based transmission of infection to health-care professionals (HCPs). The HCPs at various levels in a multispecialty health-care setup are at risk of contracting the virus. Those who are involved with performing or assisting in aerosol-generating procedures (AGPs) have a potentially higher risk of developing the infection. The AGPs involve a wide range of procedures such as pulmonary function testing, high-flow oxygen administration, endotracheal intubation, nebulization, application of ventilators, weaning and extubation, bronchoscopy, tracheostomy, and cardiopulmonary resuscitation. Hence, understanding the overall nature of the disease is of vital importance to develop preventive strategies to reduce transmission of the virus through aerosols. This review article intends to elucidate the port of entry associated with SARS-CoV-2 infection and its spread through the AGPs. We also intend to focus on methods to prevent aerosol-related transmission of infection to HCPs by illustrating clinically practiced evidence-based protocol followed in our multispecialty health-care setup.



Chris Sara Mathew, Mohammed Dhafer AlAhmari

Strategies before Intubation in COVID-19: An Evidential Update

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S24 - S28]

Keywords: Bilevel positive airway pressure, coronavirus disease-19, continuous positive airway pressure, dispersion, high flow nasal cannula, intubation, prone position

   DOI: 10.4103/ijrc.ijrc_8_21  |  Open Access | 


The coronavirus disease-19 (COVID-19) is impacting large patient populations, resulting in respiratory compromise, necessitating artificial respiratory supports. Early treatment modalities for severe respiratory failure during the pandemic focused on early intubation and invasive ventilation, as this was considered to be more effective than noninvasive respiratory strategies. However, emerging evidence proved that noninvasive respiratory supports such as noninvasive ventilation, high flow nasal cannula along with prone positioning might have a more significant and positive role than initially thought during the pandemic. Reflective evidence also suggests the utility of noninvasive respiratory supports as appropriate bridging adjuncts in the early stages of the disease process and has the potential to prevent intubation or invasive ventilation. This narrative review focusses on various strategies that are attempted in COVID-19 patients to avoid endotracheal intubation.



Sriharsha Tatineni, Vishal Shanbhag

Prone Positioning in Awake and Asleep Patients with COVID-19

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S29 - S33]

Keywords: COVID-19, prone positioning, prone ventilation, SARS-CoV, self-proning

   DOI: 10.4103/ijrc.ijrc_10_21  |  Open Access | 


Prone positioning has been found to be beneficial in both awake (self-proning) and mechanically ventilated population with acute respiratory distress syndrome due to severe COVID-19. Since the process has the potential to avoid possible intubation in a certain group of patients, prone positioning should be considered early on during COVID-19 treatment. With stepwise and careful approach involving a dedicated team of clinicians and with the help of adequate monitoring, benefits of the process can be achieved. It can contribute to offloading of resources and manpower burden in the pandemic if applied timely in the recommended group of patients.



Jose Chacko, Muhammed Unais

Pharmacologic Treatment of COVID-19: Evidence-Based Update

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S34 - S38]

Keywords: Antiviral agents, COVID-19 pandemic, interleukin inhibitors, pharmacotherapy, steroids

   DOI: 10.4103/ijrc.ijrc_40_21  |  Open Access | 


The COVID-19 pandemic continues to pose challenges on an unprecedented scale to health-care systems across the world. Mortality from COVID-19 remains low, and survival has improved compared to the early stages of the pandemic. Several new and repurposed therapeutic modalities continue to emerge as a part of our armamentarium to combat the damage triggered by the Severe Acute Respiratory Syndrome Coronavirus-2 virus. It is unclear if the more favorable clinical outcomes are attributable to specific pharmacological agents or improved care overall, as health-care systems attain increasing experience with a complex disease process. This review aims to provide an updated review of various pharmacological therapies that have been evaluated in the treatment of COVID-19 infection.



Thomas Billyard

Respiratory Support for Patients with COVID-19 Disease

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:4] [Pages No:S39 - S42]

Keywords: COVID-19, noninvasive ventilation, ventilation

   DOI: 10.4103/ijrc.ijrc_9_21  |  Open Access | 


Covid-19 disease is typified by respiratory symptoms. In severe cases respiratory failure occurs and must be carefully managed. Management can include supplementary oxygen therapy, non-invasive and invasive ventilation. In this article we describe the techniques shown to be effective in this patient group and highlight areas where future research is needed to guide the best.



Amy L. Kloosterboer, Melissa A. Vogelsong, Jessica L. Brodt

Beyond the Ventilator - Cardiovascular Management in SARS-CoV-2 Infection

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:7] [Pages No:S43 - S49]

Keywords: Cardiovascular, cor pulmonale, coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2

   DOI: 10.4103/ijrc.ijrc_105_20  |  Open Access | 


The novel corona virus, severe acute respiratory syndrome coronavirus 2 has spread worldwide since late 2019, with clinical manifestations of coronavirus disease 2019 (COVID-19) ranging from asymptomatic to respiratory impairment to multiorgan dysfunction with life-threatening cardiovascular complications. The mechanism of cardiovascular involvement is likely multifactorial, hypothesized to include direct myocardial injury, secondary injury due to the inflammatory response, and macro- and microthrombotic complications due to hypercoagulability. Acute cor pulmonale and pulmonary embolism are cardiovascular causes of serious morbidity and mortality, and myocarditis and Takotsubo syndrome have also been reported. It is not clear if arrhythmias represent a primary viral effect or a secondary effect of disease severity, though certain pharmacotherapies such as hydroxychloroquine may increase this risk. Point-of-care ultrasound and echocardiography are important tools for the screening and monitoring of these potential complications. Cardiovascular decompensation must be managed supportively with the escalation of vasoactive support, inhaled vasodilators, and consideration of mechanical circulatory support. Many questions remain and ongoing study is required to optimize care of the patient with cardiovascular complications of COVID-19.



Johnson Alex, Gauri Nadkarni Choudhary

Psychological Impact: Unseen Effects of COVID-19

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S50 - S54]

Keywords: Anxiety, COVID-19, depression, posttraumatic stress disorder, psychological burden

   DOI: 10.4103/ijrc.ijrc_137_20  |  Open Access | 


Impact of COVID-19 on mental health has affected various dimensions of human life. Various emergency government decisions and policies were developed during this period. Forced implementation of lockdown and quarantine during the pandemic made a significant impact on the general public and frontline health-care workers. The uncertainty due to COVID-19 caused major psychological problems such as anxiety, depression, stress, uncontrolled fear, and significant lifestyle changes. It has affected the world economy and also changed education and learning process.



Rakhee Goyal, Rohan Sharma

Pediatric COVID: How is it Different From Adults?

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:5] [Pages No:S55 - S59]

Keywords: COVID-19, multisystem inflammatory syndrome, pediatric, spreaders

   DOI: 10.4103/ijrc.ijrc_41_21  |  Open Access | 


COVID 19 pandemic has affected the world for more than one year now. It has had impact on children as well, but the numbers have been fewer than adults, with lesser morbidity. Children have been commonly asymptomatic and are suspected to be the spreaders to the more susceptible part of the community. Nasopharyngeal swab testing is difficult and challenging in smaller children, and therefore their results should be interpreted with caution. Multisystem involvement has been seen in some children who required ICU admission. Most centers treated these cases as a multisystem inflammatory syndrome and used vasoactive agents for support. Overall, children showed lower morbidity and mortality all over the world.



Uthara Vijai Kumar

Post-COVID-19 Sequelae

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:4] [Pages No:S60 - S63]

Keywords: COVID-19-associated pulmonary aspergillosis, post-COVID-19 sequelae, pulmonary fibrosis, thromboembolic disease

   DOI: 10.4103/ijrc.ijrc_30_21  |  Open Access | 


COVID-19 is a new disease and the acute clinical presentation is mostly clear now. It is also known now that the disease may have sequelae affecting various systems. The respiratory sequelae include pulmonary fibrosis due to the immune-mediated mechanisms that follow a cytokine storm, diffuse alveolar damage, and microvascular thrombosis. A decline in lung function may be seen in patients who still have residual symptoms and hypoxia. COVID-19-associated pulmonary aspergillosis, a well-recognized complication, especially in patients with acute respiratory distress syndrome, has emerged as a significant risk factor for increased mortality. Fatigue is a common symptom that patients come back with, in the post-COVID period. Dyspnea without hypoxia has been attributed to respiratory muscle dysfunction and deconditioning resulting in decreased exercise tolerance. Palpitation is another common persisting symptom. Thromboembolic disease, a common association during the acute phase of illness, is not an uncommon entity that is seen even after “recovery” from COVID-19. Thromboembolic events causing stroke have been identified as an immediate complication of COVID-19, but can occur during the recovery phase as well, in high-risk patients. The return of smell and taste sensations could take a few weeks to months even after complete recovery from the illness. Mood swings, anxiety, and sleep deprivation have all been reported by patients recovering from this viral illness. The last 14 months have been feverishly spent in trying to understand this particular disease, but the long-term complications of COVID-19 are still elusive.


Case Report and Literature Review

Subash P. Nandalan, Mathew Patteril

Emergency Management of Refractory Hypoxemia in Mechanically Ventilated Patients with COVID-19 Acute Respiratory Distress Syndrome

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:6] [Pages No:S64 - S69]

Keywords: COVID-19, refractory hypoxemia, ventilation

   DOI: 10.4103/ijrc.ijrc_7_21  |  Open Access | 


Covid-19 disease has had a significant impact on intensive care facilities worldwide. In ventilated patients with Covid-19 ARDS, refractory hypoxemia is a particularly challenging scenario. This article presents a case study and explores a systematic approach to the management of refractory hypoxemia. Current evidence base for Covid-19 medical management is discussed. It is emphasized that one must adhere to evidence based principles of ARDS management.



Ravi Andrews, Binoj K. Mathew

COVID-19: A Patient's Perspective

[Year:2021] [Month:April] [Volume:10] [Number:S1] [Pages:4] [Pages No:S70 - S73]

Keywords: CoV-19, patient's perspective, personal experience

   DOI: 10.4103/ijrc.ijrc_15_21  |  Open Access | 


COVID-19 has been an illness like no other, spreading across nations, sparing none, and claimed so many lives. The following are narratives of two patients who suffered from COVID-19: The first is a consultant nephrologist who developed hypoxia due to COVID-19, required high-flow oxygen therapy, and awake proning but was fortunate to recover from that stage without mechanical ventilation. The second is a biomedical engineer in the Middle East who developed severe COVID-19, was intubated and ventilated, needed a tracheostomy, and then recovered slowly back to health. This invited article includes a narrative of their experiences and personal perspectives.


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