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BACKGROUND: Pulmonary nocardiosis is a rare but a life-threatening infection caused by Nocardia spp. The diagnosis is often missed and delayed resulting in delay in appropriate treatment and thus higher mortality. AIM: In this study, we aim to evaluate the clinical spectrum and outcome of patients with pulmonary nocardiosis. METHODS: A retrospective, 5-year (2009-2014) review of demographic profile, risk factors, clinical manifestations, imaging findings, treatment, and outcome of patients with pulmonary nocardiosis admitted to a tertiary care hospital. RESULTS: The median age of the study subjects was 54 years (range, 16-76) and majority of them (75%) were males. The risk factors for pulmonary nocardiosis identified in our study were long-term steroid use (55.6%), chronic lung disease (52.8%), diabetes (27.8%), and solid-organ transplantation (22.2%). All the patients were symptomatic, and the most common symptoms were cough (91.7%), fever (78%), and expectoration (72%). Almost two-third of the patients were initially misdiagnosed and the alternative diagnosis included pulmonary tuberculosis (n = 7), community-acquired pneumonia (n = 5), lung abscess (n = 4), invasive fungal infection (n = 3), lung cancer (n = 2), and Wegener's granulomatosis (n = 2). The most common radiographic features were consolidation (77.8%) and nodules (56%). The mortality rate for indoor patients was 33% despite treatment. Higher mortality rate was observed among those who had brain abscess (100.0%), HIV positivity (100%), need for mechanical ventilation (87.5%), solid-organ transplantation (50%), and elderly (age > 60 years) patients (43%). CONCLUSION: The diagnosis of pulmonary nocardiosis is often missed and delayed resulting in delay in appropriate treatment and thus high mortality. A lower threshold for diagnosing pulmonary nocardiosis needs to be exercised, in chest symptomatic patients with underlying chronic lung diseases or systemic immunosuppression, for the early diagnosis, and treatment of this uncommon but potentially lethal disease. Despite treatment mortality remains high, especially in those with brain abscess, HIV positivity, need for mechanical ventilation, solid-organ transplantation, and elderly.

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Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. 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.

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We describe the case summary of a 70-year-old man diagnosed with interstitial lung disease due to prolonged nitrofurantoin therapy. Despite honeycombing confirmed by computed tomography of the thorax, symptoms and radiographic findings disappeared within 1 month after withdrawal of nitrofurantoin. The case highlights the fact that nitrofurantoin-induced lung disease may run a benign course and respond favorably despite radiographic evidence of established lung fibrosis (honey combing).

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Transbronchial lung biopsy via fiberoptic bronchoscope is an extremely useful technique by which bronchial as well as lung biopsies along with brushings and washings can be easily and safely taken. Fiberoptic bronchoscopy (FOB) was performed and biopsies were done in 250 patients. In addition, bronchial brushings and washings were also taken in 140 and 115 cases, respectively. Adequate material was obtained in 242 cases. The cases were broadly classified into neoplastic and nonneoplastic categories. Malignancies and specific granulomatous diseases, tuberculosis and sarcoidosis were the main diseases diagnosed. Brushings showed a sensitivity of 88.2% and a specificity of 98.9% for the diagnosis of neoplasms. On the other hand, washings had only a 34.9% sensitivity and a 98.6% specificity in diagnosing neoplastic disorders. We concluded that FOB is a safe and effective tool in the diagnostic work-up of suspected malignancies and neoplastic lung diseases.

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BACKGROUND AND AIMS: To understand the practice patterns of noninvasive ventilation (NIV) use by Indian physicians. SUBJECTS AND METHODS: Around three thousand physicians from all over India were mailed a questionnaire that could capture the practice patterns of NIV use. RESULTS: Completed responses were received from 648 physicians (21.6%). Majority (n = 469, 72.4%, age 40 +/- 9 years, M:F 409:60) use NIV in their clinical practice. NIV was most exclusively being used in the ICU setting (68.4%) and the commonest indication for its use was chronic obstructive pulmonary disease (COPD) (71.4%). A significant number did not report use of a conventional ventilator for NIV support (62%). Oronasal mask was the overwhelming favorite among the sampled physicians (68.2%). In most of the cases, the treating physician initiated NIV (60.8%) and a baseline blood gas analysis was performed in only 71.1% of the cases (315/443). Nasal bridge pressure sores was the commonest complication (64.2%). CONCLUSIONS: NIV is being widely used in clinical practice in India for various indications. COPD is the most common indication for its deployment. There seems to be a marked variability in the patterns relating to actual deployment of NIV, including the site of initiation, protocols for initiation followed, and monitoring of patients.

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A description is given of the case of a young boy who presented with repeated episodes of pneumonias since childhood. In addition, he had episodes of intermittent diarrhoeas. His investigative work-up revealed a deficiency of serum immunoglobulins, that is, hypogammaglobulinaemia. The profile was suggestive of common variable immunodeficiency. Because of the relative rarity of this disease, it is often missed leading to significant morbidity. Treatment consists of immunoglobulin replacement therapy and management of recurrent infections with appropriate drugs.

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Non invasive ventilation refers to the technique of providing ventilatory support without a direct conduit to the airway. It is a promising new technique, which is particularly useful in patients with COPD. Patients with COPD are prone to develop acute exacerbations, which pushes them into acute respiratory failure. Under these circumstances, tracheal intubation and mechanical ventilation is associated with significant morbidity and mortality. A number of well conducted studies support the fact that non invasive positive pressure ventilation (NIPPV) in these circumstances reduces rates of intubation, mortality, complications and duration of hospital stay. The biggest advantage of these techniques is their simplicity, ease of implementation and improved patient comfort allowing them to retain important functions like speech, cough and swallowing. NIPPV should be instituted early in the course of acute respiratory failure due to COPD before irreversible fatigue sets in. The current thinking is that NIPPV rests the respiratory muscles allowing other therapies time to be effective. Facilities for NIPPV should be available in all hospitals admitting patients with respiratory failure. Patients with severe, stable COPD who are hypercapnic and are deteriorating despite maximal conventional treatment should definitely be offered a trial of NIPPV. In such patients NIPPV has been shown to improve quality of life, reverse blood gas abnormalities, improve exercise tolerance and reduce hospital admissions. Physicians must familiarize themselves with this promising new ventilatory technique.

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Phrenic nerve conduction studies were performed within 48 h of admission and subsequently in 29 patients (14 of whom required mechanical ventilation) with acute organophosphate (OP) poisoning. The mean (+/-SD) amplitude of the diaphragmatic compound muscle action potential (CMAP) in patients requiring mechanical ventilation (119.09 +/- 173.85 microV) was significantly lower than in those not requiring mechanical ventilation (461.63 +/- 138.69 microV) (P < 0.0001). Diaphragmatic CMAP amplitudes in ventilated patients increased with time during the course of hospitalization and were normal in 5 (36%) patients and only mildly reduced in another 6 (43%) patients prior to discontinuation of mechanical ventilation, which was undertaken 4-18 days (mean 7 +/- 3 days) after poisoning. Eleven patients (79%) were successfully weaned from mechanical ventilation at the first attempt. In the 3 (21%) remaining patients, mechanical ventilation had to be reestablished because of weaning failure. The mean (+/-SD) diaphragmatic CMAP amplitude, prior to discontinuation of ventilatory assistance, was 242.6 +/- 94.1 microV in these 3 patients. After ventilatory discontinuation, it fell to 95.5 +/- 105.8 microV. Thus, reduced diaphragmatic CMAP amplitudes correlate with the need for mechanical ventilation in acute OP poisoning.

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This study was undertaken to study early and late post extubation complications following endotracheal intubation and tracheostomy. A total 60 patients who were admitted in Dayanand Medical College and Hospital were studied prospectively. They were divided into 3 groups and were screened with various modalities like fiberoptic laryngoscopy. Bronchoscope, X-Ray Soft Tissue Neck and CT Scan, Complications like glottic edema, vocal tears, vocal granuhmas and tracheal stenosis were seen and were accordingly managed.

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Non-invasive ventilation refers to the technique of providing ventilatory support to a patient without an endo/orotracheal airway. It is a promising and rapidly upcoming new technique and is being used as first line therapy in a wide variety of conditions causing respiratory failure. The major indications for its use include respiratory failure due to a variety of causes (chest wall abnormalities, neuromuscular disease, COPD), weaning and stabilization of cardio-respiratory status before and after surgery. Patients who are candidates for this modality usually have a hypercapnic respiratory failure but are able to protect the airway and cooperate with treatment. The biggest advantage of the technique is its simplicity and avoidance of complications of intubation like trauma, infection and delayed complications like tracheal stenosis. Patient comfort is significantly improved and important functions like speech, swallowing and cough are preserved. Several purpose built ventilators are available for use including pressure preset and volume present machines, each of which have their own advantages and disadvantages in clinical practice. A range of patient interfaces is available. The initiation of non-invasive ventilation is much easier as compared to invasive ventilation and can be done for most patients in an intermediary care unit thereby cutting down treatment costs and saving precious intensive care beds. Titration of ventilatory parameters can usually be done using simple tests like oxymetry and blood gases. Several technique related problems like skin pressure sores, nasal symptoms and abdominal distension can be managed with simple measures. Non invasive ventilation has got a special and evolving role in management of COPD, both in acute exacerbations and chronic respiratory failure. In short, the advantages of this form of ventilation are numerous and physicians must familiarize themselves with this new technique, facilities for which should be available in all hospitals admitting patients with respiratory failure.

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Two hundred samples from sputum (160), bronchial secretions (35) and pleural aspirate (5) were analysed from patients of bronchopulmonary disorders. One hundred nine samples (54.5%) were positive for the fungi. Candida species (50%) were the predominant fungus isolated, followed by Aspergillus species (3.5%). Among various species of Candida, C. albicans accounted for 29.5% cases of bronchopulmonary disorders.

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Flumazenil is a potent-specific benzodiazepine receptor antagonist that has been shown to reverse CNS depressant effects mediated by benzodiazepine agonists. These agonists are known to affect the interaction of gamma aminobutyric acid (GABA) with its receptor. Because the action of volatile anesthetic agents may be mediated by GABA, the authors determined the MAC of isoflurane in 16 dogs before and after one of three doses of intravenous flumazenil (0.15, 0.3, and 0.45 mg/kg) or the drug vehicle. The flumazenil produced a reduction in MAC from 1.39 +/- 0.15% (mean +/- SD) to 1.23 +/- 0.11% after 0.15 mg/kg (P less than 0.05), from 1.50 +/- 0.35% to 1.08 +/- 0.20% after 0.3 mg/kg (P less than 0.01), and from 1.45 +/- 0.14% to 1.09 +/- 0.08% after 0.45 mg/kg (P less than 0.01). Administration of drug vehicle produced no change in MAC. This reduction in isoflurane requirement by flumazenil may be due to its benzodiazepine receptor agonist action or its analgesic effect.

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The physiologic responses to acute pneumothorax were investigated in awake, standing sheep. Pleural pressure (Ppl) was raised in graded increments by injecting air from a 500 ml syringe into the pleural cavity of eight sheep to produce pneumothorax volumes of 0, 17, 35 and 45 ml.kg-1. At the maximum value of 45 ml.kg-1 (approximately equal to 1,400 ml), Ppl at end-expiration was raised to 10 +/- 2 mmHg (mean +/- SD) whereas end-inspiratory Ppl remained negative in half the sheep as the result of increased thoracic pressure swings. The most striking haemodynamic impairment was a 22% fall in stroke volume. Cardiac output, however, remained fixed at baseline values as a result of a 28% rise in heart rate. Although hypotension has been commonly held as a consequence of severe pneumothorax, mean systemic arterial pressure increased, rising by 19% in the entire group at the maximal pneumothorax tolerated. Pulmonary gas exchange was significantly disrupted by pneumothorax, as indicated by both a 40% fall in Pao2 and a 19% reduction in arterial oxygen content. Despite a reduction in tidal volume, the sheep initially remained eucapnic by generating an increased respiratory rate and slightly increasing minute-ventilation. However, at pneumothorax volumes of 45 ml X kg-1, the sheep were no longer able to sustain minute-ventilation and a small rise in PaCO2 followed. The reduced arterial oxygen content and the fixed cardiac output led to a progressive reduction in systemic oxygen transport.(ABSTRACT TRUNCATED AT 250 WORDS)

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Although esophageal pressures have been substituted for direct pleural pressure measurement in humans, we have investigated the validity of this approach under circumstances when left and right pleural pressures are not equal. Esophageal and bilateral pleural pressures in awake sheep were compared by using matched balloon catheters in close proximity. In standing sheep, both end-expiratory pressures and inspiratory pressure swings were similar in all three catheter systems. However, when pleural pressures were made unequal, as during lateral recumbency or unilateral pneumothorax, the esophageal pressure reflected predominantly the right pleural pressure. These results suggest that esophageal pressures are useful estimates of pleural pressure under normal conditions when pleural pressures are equal bilaterally. However, the usefulness of esophageal pressures is limited in the presence of unilateral pneumothorax or other conditions where left and right pleural pressures are unequal. In the lateral decubitus position, positive end-expiratory pleural pressures were consistently observed. This was believed to be due to a combination of contraction of expiratory muscles, rapid respiratory rate resulting in insufficient expiratory time to reach an equilibrium pressure, and increased airways resistance resulting from compression of the dependent lung by the abdominal viscera. A single study in a paralyzed ventilated sheep showed less positive expiratory pressures, which were further reduced to zero or less when the respiratory rate was slowed to 10 breaths/min.

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