Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition)

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Consensus & Evidence-based INOSA Guidelines 2014 (First edition)

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or ≥ 15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint recommendations of Indian Chest Society and National College of Chest Physicians (India)

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society and the National College of Chest Physicians (India) have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definition, epidemiology and disease burden, (b) disease assessment and diagnosis, (c) pharmacologic management of stable COPD, (d) management of acute exacerbations; and (e) non-pharmacologic and preventive measures.

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Hydatid lung disease: an analysis of five years cumulative data from Kolkata

BACKGROUND AND OBJECTIVE

There is scarcity of clinical data regarding hydatid lung disease from Indian subcontinent. In this retrospective study we analyzed the cumulative data over five year's period from two tertiary care hospitals of Kolkata to determine the presentation, treatment and outcome of hydatid disease of lung.

METHOD

We analyzed 106 patients on the basis of clinical findings, radiological findings [chest X-ray--PA and lateral view, CT scan of thorax and upper abdomen, ultrasonography (USG) of thorax and upper abdomen] and serological test IgG ELISA (enzyme linked immunosorbent assay) against echinococcus granulosus antigen along with the mode of diagnosis, indications and types of surgery, and outcome of treatment with chemotherapy (albendazole), surgery and combined surgery with chemotherapy.

RESULT

There was female preponderance with median age of presentation 33 years with interquartile range of 7. At the time of diagnosis 14.15% patients were asymptomatic. Cough was the commonest symptom (73.58%) followed by chest pain (54.72%). Single sharply demarcated round or oval homogenous opacity was the commonest radiological sign (81.13%). Complicated cysts such as lung abscess, pleural involvement, pneumonitis and fibrosis were noted in 10.38%, 13.21%, 7.55% and 11.32% cases respectively. We found that serological test was only 77.01% sensitive. Eighty-two (86.32%) patients underwent surgery, and 56.10% of them received additional chemotherapy with albendazole. The types of operation performed were pericystectomy (in 91.46% cases), lobectomy (in 6.10% cases) and pneumonectomy (in 2.44% cases). Perioperative mortality was nil but morbidity was found in 10.98% cases with empyema (8.54%), the commonest complication. Thirteen inoperable patients were treated with albendazole, among them 8 showed reduction of cyst-size, 3 showed no change and 2 patients showed obliteration of cyst.

CONCLUSION

Surgery is a safe and effective way of treatment for thoracic hydatid cyst along with perioperative albendazole therapy. There is a scope for chemotherapy with albendazole in inoperable cases.

The Keith Edward scoring system: A case control study

OBJECTIVE

The World health organization (WHO) has accepted Keith Edward scoring system for the diagnosis of childhood tuberculosis (TB). In the present study, we evaluated this scoring system.

METHODS AND RESULTS

We included 53 children with confirmed TB involving different organs, admitted in NB Medical College, during two years period as cases; and 50 randomly selected, age, sex, and organ matched confirmed non-TB cases as controls. We noticed 15.1% false negative and 22% false positive results in our study, and the scoring system had 84.9% sensitivity, 78% specificity, and 80.36% positive predictive value. Likelihood ratio positive (LR+) was 3.86, likelihood ratio negative (LR-) was 0.19, and overall agreement was 81.55%. We observed that Keith Edward scoring system was less effective in children suffering from non-TB chronic diseases (false positive rate: 45.5%). We found no significant difference in nutritional status between study and control groups (P = 0.65). We noticed that more than 15-mm indurations for tuberculin test were specific for TB in children.

CONCLUSION

We concluded that Keith Edward scoring system is good for public health purpose, but there is a scope for improvement, and further study is required for this purpose.

Polysomnographic profile in a sleep laboratory in Kolkata: a retrospective analysis of 714 cases

In this retrospective analysis, all patients (n=714; male=590; female=124 and female male ratio = 1: 4.76) came to Pulsar, a sleep laboratory of Kolkata, for polysomnography during ten years period were analyzed. More than half (62.46%) cases were between 41-60 years and 14.43% cases between 61-80 years age group. Fifty-two percent cases were referred by pulmonologists, followed by internist (15%), and 7% cases were self referred. Though obstructive sleep apnea was responsible for increased cardiovascular mortality and resistant hypertension, only 4% cases were referred by cardiologists. We observed hypertension as co-morbidity in 52.63% cases and ischemic heart disease in 22.83% cases. Snoring was the presenting complain in 98.88% cases, chocking was present in 48.88% cases and excessive daytime sleepiness was found in 96.64% cases. Females showed comparatively higher frequency of sleep disordered breathing than males with increasing basal metabolic rate. Nocturnal fall of SPO2 below 90% was observed in 86.97% of study population. We found abnormal respiratory disturbance index (> 5/hr of sleep) in 84.59% of our patients, normal respiratory disturbance index (< or = 5/hr of sleep) in 9.94% cases and isolated nocturnal hypoxemia in 5.46% cases (74.36% of the last category having obstructive airway disease). Snoring with respiratory disturbance index (RDI) < or = 5/hr was observed in 102 cases, of them 81.37% had simple snoring without significant arousal whereas 18.63% had multiple sleep fragmentation. We estimated that 84.06% of males, 87.10% of females and 84.59% of study population had obstructive sleep apnea. Split night polysomnography was performed in 362 cases, and of them 15.47% cases could not tolerate continuous positive airway pressure (CPAP) due to local or psychological reasons. In the present one time split-night CPAP titration study, we could not correct OSA in 19.06% subjects. Inadequate correction of hypoxemia due to co-morbid condition like COPD, asthma, obesity, hypothyroidism was the main responsible factor (49.28%). Treatment with CPAP was effective in 68.23% cases in first attempt. More than half of the cases (62.42%) required 10 cm of H20 or less CPAP.

Massive haemothorax: a presentation of pulmonary arteriovenous malformation

Arteriovenous malformations of the lung are relatively uncommon lesions with varied clinical presentation. Nearly half of these are associated with Osler-Rendu-Weber disease. Magnetic resonance angiography is an accurate and non-invasive diagnostic modality. We report a case of a 56-year-old male who had massive haemothorax due to rupture of a pulmonary arteriovenous malformation arising from the right interlobar artery.

Diagnosis of tuberculosis

Presence of tuberculous infection in the body does not necessarily mean disease. Any diagnostic work up of the disease starts from a high index of clinical suspicion. However, diagnostic modalities include: (a) Isolation of the bacillus; (b) Immunologic tests; (c) Chemical markers; (d) FNAC, bronchoscopy and bronchoalveolar lavage; (e) Amplification systems. There exists controversies and limitations about the disease process even then.

Fibrothorax--problem, profile and prevention

Fibrothorax is a common clinical condition found in everyday clinical practice. The clinical horizon of fibrothorax can be differentiated into pleural and lung parenchymal fibrosis. The two groups can be differentiated clinically and also by investigations. A thorough understanding of the process gives one better knowledge as to their different aetiologies, presentations and prognoses. The nature of prevention of this meance varies in these types. Patient's drug compliance status is important in preventing primary lung parenchymal fibrosis whereas physician's adequate care for pleural drainage is important in the prevention of pleural fibrosis. In this prospective study, observations were made on (1) the clinical presentation of 100 cases of fibrothorax and its relation to the primary disease, (2) aetiological distribution of the cases of fibrothorax and (3) scope of prevention, if any.