Clinical characteristics and outcome of H1N1 (2009) pneumonia with special reference to radiological features in a tertiary care hospital in northern Karnataka

Background: In late March 2009, an outbreak of respiratory illness, later proved to be caused by swine origin influenza A (H1N1) virus (S-OIV) was identified in Mexico. Thereafter many countries worldwide have reported the incidence of this pneumonia. The present study was undertaken to evaluate the clinical characteristics and radiological features of positive cases of confirmed Influenza A H1N1 (2009) infection in a tertiary care hospital in northern part of Karnataka. Material and Methods: A retrospective analysis of medical charts, laboratory investigations and radiographs of 57 positive cases of Influenza A H1N1 (2009) infection was done. Throat swab of all these patients were confirmed by real time RT- PCR assay (reverse transcriptase polymerase chain reaction method). Results: A total of 57 cases were infected with influenza A H1N1 (2009) virus. They belonged to 20 to 40 years of age, with the mean age being 35. Acute onset cough, fever and breathlessness were the most common clinical presentation. Some of them had chest pain, sore throat, rhinitis, hemoptysis and vomiting. Twenty patients had co-morbid conditions like type 2 diabetes mellitus, IHD and one of them was a case of carcinoma breast on chemotherapy. Features of leucopenia, leucocytosis, thrombocytopenia, raised liver function parameters and raised blood serum creatinine were the major laboratory features. Radiologically, almost all of the patients had confluent ground glass appearance on chest radiographs, with bilateral distribution of the patchy infiltrations in multiple lung zones. A typical consolidation was conspicuous by its absence. Pleural effusion was present in 14% of the cases. A total of 35 patients required mechanical ventilation and 26 of them succumbed to death. Hypoxemia and thrombocytopenia were the major risk factors for the mortality with H1N1 pneumonia. It was also observed that involvement of four or more lung zones and bilateral peripheral opacities was associated with higher mortality in these patients. Raised liver function test parameters and raised serum creatinine levels were the indicators for development of MODS. Mortality on mechanical ventilator for these patients was very high (p<0.0008). Conclusions: The present study revealed the serious nature of H1N1 pneumonia with high mortality due to ARDS and MODS in patients requiring mechanical ventilation. This emphasizes the need for early institution of the antiviral therapy and close monitoring in these patients

Pulmonary manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed

Prevalence and correlates of osteoporosis in chronic obstructive pulmonary disease patients in India

Background: Chronic obstructive pulmonary disease (COPD) is a syndrome of progressive airflow limitation caused by the abnormal inflammatory reaction of the airway and lung parenchyma. Osteoporosis is one of the major extrapulmonary manifestations of COPD. The, prevalence of osteoporosis in COPD patients in Indian population is unknown. Objectives: To study the prevalence of osteoporosis in COPD and to define various risk factors associated with reduced bone mineral density (BMD) in COPD. Materials and Methods: The study was done in the department of Pulmonary Medicine of a tertiary care hospital. All the diagnosed cases of COPD according to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines were included in this study. The present study was a prospective study in for a period of 1 year. A brief history of the patients was taken, especially regarding duration of illness, number of exacerbations in the past 3 years, smoking in pack years, and history of steroid use (both systemic and inhaled steroids) after which cumulative dose of steroids was calculated. Spirometry was done in all these patients to stage the severity of COPD according to GOLD criteria. DEXA scan of the lumbar spine was done using bone densitometer to determine osteoporosis. A world Health Organization (WHO) criterion for definition of osteoporosis was applied and patients with T-score of > –2.5 standard deviation (SD) were diagnosed to have osteoporosis, –1 SD to –2.5 SD were diagnosed to have osteopenia and 3 (OR: 30.3, 95% CI: 4.74-200, P 1,000 mg (OR: 7.35, 95% CI: 0.92-58.5, P < 0.04) were observed to be significant risk factors for osteoporosis in COPD patients. Conclusions: In the present study, the prevalence of osteoporosis was 66.6% and another 19.6% had osteopenia. As the severity of COPD increased, the risk of osteoporosis increased. GOLD stage III and stage IV patient had significantly lower BMD as compared to stage I and stage II of COPD disease. Stage IV COPD disease, use of oral or parenteral glucocorticoids, and repeated number of exacerbations were found to be independent risk factors for osteoporosis in COPD patients. Thus, high clinical suspicion and early diagnosis and treatment is required in the evaluation of osteoporosis in COPD patients so that the quality of life can be improved in these patients

Prevalence and correlates of osteoporosis in chronic obstructive pulmonary disease patients in India

Background: Chronic obstructive pulmonary disease (COPD) is a syndrome of progressive airflow limitation caused by the abnormal inflammatory reaction of the airway and lung parenchyma. Osteoporosis is one of the major extrapulmonary manifestations of COPD. The, prevalence of osteoporosis in COPD patients in Indian population is unknown. Objectives: To study the prevalence of osteoporosis in COPD and to define various risk factors associated with reduced bone mineral density (BMD) in COPD. Materials and Methods: The study was done in the department of Pulmonary Medicine of a tertiary care hospital. All the diagnosed cases of COPD according to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines were included in this study. The present study was a prospective study in for a period of 1 year. A brief history of the patients was taken, especially regarding duration of illness, number of exacerbations in the past 3 years, smoking in pack years, and history of steroid use (both systemic and inhaled steroids) after which cumulative dose of steroids was calculated. Spirometry was done in all these patients to stage the severity of COPD according to GOLD criteria. DEXA scan of the lumbar spine was done using bone densitometer to determine osteoporosis. A world Health Organization (WHO) criterion for definition of osteoporosis was applied and patients with T-score of > –2.5 standard deviation (SD) were diagnosed to have osteoporosis, –1 SD to –2.5 SD were diagnosed to have osteopenia and < –1 SD as normal. Statistical analysis for association of COPD with osteoporosis was done using chi-square test. Risk factors for osteoporosis were identified by univariate and multivariate logistic regression analysis. Results: A total of 102 COPD patients were included in the study. Among these, 68 patients (66.6%) had osteoporosis and 20 patients (19.6%) had osteopenia. Majority (64.7%) of the patients who had osteoporosis had stage III and stage IV COPD disease. It was observed that as the severity grade of COPD increased, the risk of osteoporosis also increased. The bone mineral density (BMD) showed a significant difference among different stages of COPD. As the severity of the stage of COPD increased, BMD decreased. It was also observed that patients with lower body mass index (BMI) had higher prevalence of osteoporosis (37.3%) as compared to overweight patients. On univariate analysis, it was observed that risk factors for osteoporosis were female sex, higher number of exacerbations, BMI, and severity of COPD. After using multivariate logistic regression analysis, stage IV COPD (odds ratio (OR): 34.48, 95% confidence interval (CI): 1.59-1,000, P < 0.02), number of acute exacerbations >3 (OR: 30.3, 95% CI: 4.74-200, P < 0.01), and steroid cumulative dose >1,000 mg (OR: 7.35, 95% CI: 0.92-58.5, P < 0.04) were observed to be significant risk factors for osteoporosis in COPD patients. Conclusions: In the present study, the prevalence of osteoporosis was 66.6% and another 19.6% had osteopenia. As the severity of COPD increased, the risk of osteoporosis increased. GOLD stage III and stage IV patient had significantly lower BMD as compared to stage I and stage II of COPD disease. Stage IV COPD disease, use of oral or parenteral glucocorticoids, and repeated number of exacerbations were found to be independent risk factors for osteoporosis in COPD patients. Thus, high clinical suspicion and early diagnosis and treatment is required in the evaluation of osteoporosis in COPD patients so that the quality of life can be improved in these patients

Bone mineral density among elderly patients with chronic obstructive pulmonary disease patients in India

Background: Osteoporosis is one of the major extra-pulmonary manifestations of chronic obstructive pulmonary disease (COPD), which limits the physical activity. The present study was undertaken to study the bone mineral density (BMD) and osteoporosis in the elderly COPD patients. Materials and Methods: This was a cross-sectional study carried out among elderly COPD patients. After a detailed clinical history spirometry was done to stage the severity of COPD. DEXA scan of the lumbar spine was performed using bone densitometer to determine osteoporosis. Statistical analysis was based on Chi-square test. Risk factors were identified by univariate and multivariate logistic regression analysis. Results: A total of 70 elderly COPD patients were included. Fourty-six patients (65.7%) had osteoporosis and 13 (18.6%) had osteopenia. Majority of the osteoporosis patients had stage III or stage IV COPD disease (77.2%). As the severity grade of COPD increased, the risk of osteoporosis also increased. Also, with the increasing severity of COPD, BMD decreased. Patients with lower body mass index (BMI) had higher prevalence of osteoporosis (45.7%). Using multivariate regression analysis, stage IV COPD, number of acute exacerbations >3 and steroid cumulative dose >1000 mg were independent risk factors for osteoporosis in elderly COPD patients. Conclusions: The prevalence of osteoporosis was 65.7%, and 18.6% had osteopenia. Stage III and IV patients had significantly lower BMI in elderly COPD patients. High clinical suspicion and early diagnosis and treatment are required in the evaluation of osteoporosis in elderly COPD patients

Clinical significance of microalbuminuria and hypoxemia in patients with chronic obstructive pulmonary disease

Background: Cardiovascular disease is a major cause of mortality in chronic obstructive pulmonary disease (COPD), particularly in patients with mild to moderate severity. Microalbuminuria (MAB) has a strong association with cardiovascular events and death, and it reflects generalized endothelial dysfunction. There is evidence of vascular dysfunction in patients with COPD. Objectives: (a) To study the prevalence of MAB in stable COPD patients. (b) To determine the relationship of MAB with clinical and physiological descriptors of COPD severity and cardiovascular risk factors. Materials and Methods: A cross-sectional study in 150 COPD patients over a period of 1 year. Lung function, 6-min walk distance, smoking history, arterial blood pressure (BP), BODE index, and arterial blood gases were measured. Screening for MAB was done by measuring urinary albumin-to-creatinine ratio in a random spot urine collection. Stepwise logistic regression was performed using MAB as the dependent variable. P < 0.05 was taken as statistically significant. Results: Forty-six patients (30.0%) had MAB. There was negative association between hypoxemia and MAB. Stepwise logistic regression analysis with MAB as the dependent variable showed smoking (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.54-3.41), lower forced expiratory volume in 1 s % (OR: 1.04; 95% CI: 0.98-1.10), and PaO2 (OR: 0.68; 95% CI: 0.57-0.83) as independent predictors of MAB. Conclusions: MAB in severe COPD patients should be examined in regular periods for risk of cardiovascular morbidity or mortality

Critical illness myopathy and polyneuropathy - A challenge for physiotherapists in the intensive care units

The development of critical patient related generalized neuromuscular weakness, referred to as critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), is a major complication in patients admitted to intensive care units (ICU). Both CIP and CIM cause muscle weakness and paresis in critically ill patients during their ICU stay. Early mobilization or kinesiotherapy have shown muscle weakness reversion in critically ill patients providing faster return to function, reducing weaning time, and length of hospitalization. Exercises in the form of passive, active, and resisted forms have proved to improve strength and psychological well being. Clinical trials using neuromuscular electrical stimulation to increase muscle mass, muscle strength and improve blood circulation to the surrounding tissue have proved beneficial. The role of electrical stimulation is unproven as yet. Recent evidence indicates no difference between treated and untreated muscles. Future research is recommended to conduct clinical trials using neuromuscular electrical stimulation, exercises, and early mobilization as a treatment protocol in larger populations of patients in ICU

Effects of oral montelukast on airway function in acute asthma: A randomized trial

Background: The role of leukotriene receptor antagonist is well known in the management of chronic asthma, but their efficacy in acute exacerbation of asthma is unknown. The present study was done to evaluate the clinical efficacy of oral montelukast as an add on therapy to the usual standard therapy of acute attack of bronchial asthma. Materials and Methods: A randomized single-blinded controlled study was conducted in a tertiary care teaching hospital. A total of 162 patients with age >18 years of acute exacerbations due to bronchial asthma were included in the study. The patients were randomized into two study and control groups. The study group patients received oral montelukast (10 mg) once daily for 2 weeks, while the control group received a placebo. All the patients received standard therapy according to GINA guidelines. Improvements in lung function tests, clinical symptoms, and relapse rates were monitored at baseline, 1 week, 2 weeks, and 4 weeks. Side effects profile was also monitored. Results: A total of 160 patients were finally assessed. Seventy-eight patients belonged to study group and 82 in the control group. Baseline characteristics were similar and well matched in both groups. Mean age was 39.9 ± 15.8 years in the study group and 42.8 ± 12.8 in the control group and majority were female patients in both groups. At the end of 4 weeks, it was observed that the study group patients who received montelukast had better forced expiratory volume in 1 s (FEV1) improvement by 21% (0.21 L) as compared to the control group (P < 0.0033). It was also observed that there was a better improvement in peak expiratory flow rate (PEFR) at 2 weeks (0.4 L/s, 12%) and at 4 weeks (0.9 L/s, 23%) as compared to the control group (P < 0.0376 and P < 0.0003 respectively). There was no difference in forced vital capacity (FVC), FEV1/FVC ratio and relapse rates between the two groups. No serious adverse effects were observed during the study. Conclusions: In acute asthma exacerbations, the present study showed that additional administration of oral montelukast resulted in significantly higher FEV1at 4 weeks and PEFR at 2 weeks and 4 weeks as compared to the standard treatment alone. These findings should be confirmed by conducting a larger population-based clinical study