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   Table of Contents - Current issue
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October-December 2022
Volume 11 | Issue 4
Page Nos. 287-399

Online since Saturday, November 12, 2022

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EDITORIAL  

Managing acute exacerbation of chronic obstructive pulmonary disease: What's new? Highly accessed article p. 287
R Adhitiya Raman, Harish Mallapura Maheswarappa
DOI:10.4103/ijrc.ijrc_177_22  
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REVIEW ARTICLES Top

Managing bronchiolitis in pediatric patients: Current evidence Highly accessed article p. 291
Subhranshu Sekhar Dhal, Hiremath Sagar
DOI:10.4103/ijrc.ijrc_153_22  
Background: Acute bronchiolitis is an inflammatory process affecting small airways. Although most cases are self-limiting, it is still one of the most common causes of hospitalization below 24 months of age. Treatment is mainly supportive. The purpose of this narrative review was to look for recent evidence in the management of bronchiolitis. Methods: PubMed, EMBASE, Global Health, MEDLINE, SCOPUS, and Cochrane database searches were performed using keywords such as bronchiolitis, management, bronchodilators, nebulized epinephrine, corticosteroids, and hypertonic saline. Systematic reviews, original articles, and clinical practice guidelines with evidence for bronchiolitis management were included during our search. We excluded guidelines and clinical trials which solely focused on high-risk children, articles by a single author, and trials that are not part of a clinical practice guideline. Discussion: The safety and efficacy of various therapies for bronchiolitis such as bronchodilators, epinephrine, hypertonic saline, and corticosteroid were analyzed. Bronchodilators have not shown consistent benefits in bronchiolitis and may be tried in the selected population. Current evidence does not suggest routine use of nebulized epinephrine in bronchiolitis except as rescue therapy in selected cases. Hypertonic saline showed positive results in some studies but questions still remain regarding its effectiveness in all. Recent trials also do not support the use of systemic or inhaled corticosteroids in bronchiolitis. Conclusion: In conclusion, there is no strong evidence to routinely recommend the use of bronchodilator, epinephrine, hypertonic saline, or corticosteroids in acute bronchiolitis. Supportive care still remains the mainstay of therapy for bronchiolitis.
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A comprehensive review on the management of ARDS among pediatric patients p. 296
Anil Kumar Sapare, Yashwanth Raju Hunasagahalli Nagaraju
DOI:10.4103/ijrc.ijrc_158_22  
Pediatric acute respiratory distress syndrome (PARDS) is a complex inflammatory syndrome of lungs leading to disruption of alveolar epithelial membrane barrier in the lungs. It includes varying age groups from infants to adolescents. PARDS definition has changed over decades as current definition is given by the Pediatric Acute Lung Injury Consensus Conference group. Although most of management principles are extrapolated from adult data, physiology of Acute Respiratory Distress Syndrome (ARDS) in children is different when compared to adults. The present review mainly focused on current evidence in the management of ARDS with emphasis to pediatric population. MeSH headings such as ARDS, positive end-expiratory pressure (PEEP), and lung protective ventilation were used for searching publications in PubMed, Embase, and SciELO. Publications were limited to human studies in the past 20 years. Core ventilatory strategies in PARDS include use of low-tidal volume, higher PEEP and acceptance of permissive hypercapnia and permissive hypoxemia. Supportive strategies such as restrictive fluid therapy, prone positioning, early enteral nutrition, and adequate analgosedation remain the mainstay of management of principles. As PARDS contains heterogeneous population, personalized mechanical ventilation under umbrella of lung protective ventilator strategies such as low-tidal volume ventilation, open lung strategy, acceptance of permissive hypercapnia, and permissive hypoxia is standard of care.
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Role of nutrition in pediatric patients with respiratory failure Highly accessed article p. 302
Priti Arolkar, Girija Damle, Priyal Gala
DOI:10.4103/ijrc.ijrc_162_22  
Respiratory failure is a consequence of malfunction of the respiratory system including neuronal and cellular aspects. The most common causes in children are pneumonitis, vasculitis, pulmonary edema, cystic fibrosis, tuberculosis, asthma, foreign-body aspiration, and respiratory infections of the upper and lower airways. Reduced immunological response due to critical illness, atrophy, and increased intestinal epithelial barrier permeability results in increased susceptibility to infections and the spread of pathogens. The search strategy included a PubMed search for articles from 2000 to 2022. Malnutrition is acquired in 50% of patients admitted to the pediatric intensive care unit, with the added burden of nutritional deficits worsening preexisting malnutrition. Nutrition forms an essential component in managing respiratory conditions, with the potential to change outcomes. Enteral nutrition (EN) can reduce inflammatory cytokine activation and release, as well as maintain gastrointestinal (GI) mucosal integrity, which lowers systemic bacterial invasion and sepsis. Therefore, EN should be the preferred mode of nutrition (when clinically indicated) to parenteral nutrition. ASPEN guidelines recommend the administration of a minimum of 1.5 g/kg/ day of protein in critically ill children. Reduction in the respiratory quotient may be achieved by lowering the carbohydrate intake in infants suffering from prolonged lung disease; however, a balance of carbohydrate and fat ratios is recommended. Immunonutrition helps in reducing inflammation and pro-inflammatory cytokine levels. During pediatric acute respiratory distress syndrome, an essential target to improve lung inflammation is the GI tract. However, no disease-specific recommendation for probiotics and immunonutrients has been established in children yet.
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ORIGINAL ARTICLES Top

Diagnostic yield of direct smear, concentrated smear, liquid culture, and GeneXpert by sputum induction in smear-negative pulmonary tuberculosis patients p. 310
A Sivaprakasam, V Gangadharan, G Karthiga, P Anandeswari
DOI:10.4103/ijrc.ijrc_33_22  
Background: Spontaneous sputum smear gave negative results in clinically and radiologically suspected pulmonary tuberculosis (TB) patients. Hence, the study aimed to evaluate the diagnostic yield of induced sputum with direct smear, concentrated smear, liquid culture, and GeneXpert. Materials and Methods: This cross-sectional study was conducted on clinically and radiographically suspected TB patients who were sputum smear-negative; 88 sputum smear-negative patients underwent sputum induction, and the samples were tested for direct smear, concentrated smear, liquid culture, and GeneXpert. Descriptive analysis was carried out for frequency and proportion for categorical variables and mean and standard deviation for quantitative variables. Diagnostic yield was calculated for each test. Data analyzed using coGuide software, V.1.03. Results: The mean age of the study population was 46.87 ± 15.09 years, and male participants were the majority. The diagnostic yield of induced sputum was 19.29% compared to a direct smear. Diagnostic yield was 59.25%, 80.70%, and 94.73% for concentrated smears, liquid culture, and GeneXpert, respectively. Conclusion: Induced sputum gave a high diagnostic yield in smear-negative pulmonary TB. With induced sputum, GeneXpert gave maximum yield compared to direct smear, concentrated smear, and liquid culture.
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Prevalence of metabolic syndrome in chronic obstructive pulmonary disease and its correlation with body mass index, airflow obstruction, dyspnea, and exercise index and C-reactive protein p. 314
D Suresh Kumar, Richard Samuel, Viola Savy DSouza, Madhu Keshava Bangera
DOI:10.4103/ijrc.ijrc_44_22  
Context: Chronic obstructive pulmonary disease (COPD) is a widespread reason of disease and death in developing countries like India, although it is preventable, controllable, and treatable. Objectives: We studied the occurrence of metabolic syndrome (MetS) among cases of stable COPD and determined the correlation between stable COPD with MetS and body mass index, airflow obstruction, dyspnea, and exercise (BODE index) and C-reactive protein (CRP) titer. Methods: The study was a case–control analysis conducted on 90 patients from November 2019 to August 2020. Results: Seventy percentage of our case population belonged to Global Initiative for Chronic Obstructive Lung Disease (GOLD) Grade 1 and 2. A significant correlation between forced expiratory volume 1 s (FEV1) with body mass index (BMI), triglycerides (TGs), high-density lipoproteins (HDL), systolic blood pressure (SBP), and fasting blood sugar (FBS) was found. The higher the GOLD grade (lower FEV1), the higher the values of BMI, TG, HDL, SBP, and FBS. A negative association with MetS is related to small study population. Conclusion: Patients with MetS had significantly lower FEV1, higher mean SI, higher mean waist circumference, higher mean BMI, higher mean SBP and diastolic blood pressure, higher FBS, and higher HDL and TG. Patients with MetS showed higher BODE index and CRP titer compared to ones without it. Apart from routine vaccination, assessment of systemic comorbidities for early detection of MetS plays a pivotal role to provide best possible quality of life and utmost care to COPD patients and helps reduce mortality and morbidities of COPD.
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Comorbidities and vaccination significantly influence on Post-Coronavirus disease 19 functional and health status: A single-center experience from South India p. 321
Venkata Ramana Kandi, Tarun Kumar Suvvari, L V Simhachalam Kutikuppala, Hemanth Reddy Burugu, Sri Harsha Boppana, Venkata Dinesh Kumar Kandula, Mamtha Jadhav, Mani Kruthika Mantha
DOI:10.4103/ijrc.ijrc_57_22  
Background: Health-care specialists and clinical researchers worldwide have been concentrating more on the acute and intense phase of the coronavirus disease 19 (COVID-19) infection, but there is an exigency toward the incessant monitoring in the postdischarge period to foresee the long-lasting effects of the disease. The main objective of this study is to evaluate the post-COVID-19 health and functional status (PCFS) and the long-term health implications of severe acute respiratory syndrome coronavirus-2 infection among COVID-19 recovered patients. Materials and Methods: An observational, cross-sectional, and hospital-based study was conducted among the COVID-19 recovered patients. The PCFS scale was used as a study tool to assess the functional status. Data were entered into Excel spreadsheets 2019, and statistical analysis was performed using the SPSS version 24.0. Descriptive statistics were used, and the Chi-square test was used to determine the role of sociodemographic characteristics on questions. The statistical significance level was set at P < 0.05 (two-sided). Results: A total of 80 patients were included in the study and the mean age was 37.03 ± 15.15 years. More than half of the participants (52.5%) showed functional limitations. Fatigue (30%), anxiety (23.75%), and cough (6.25%) were noted to be persistent symptoms reported post-COVID-19 recovery. The majority (88.75%) of the study participants experienced at least one symptom post-COVID-19 and 52.5% have experienced at least one functional limitation. The presence of comorbidities (r = 0.664; likelihood ratio [LR] = 0.968), and vaccination (r = 0.700; LR = 0.611) considerably influenced the PCFS. Conclusion: Our study revealed that there is a significant limitation of PCFS among recovered patients. The presence of comorbidities and vaccination significantly correlated with the PCFS. Standard identification tools, extensive screening, and wide education of consequences related to post-COVID-19 along multicentric and global studies are the need of the hour.
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Relation of plasma high-density lipoproteins-cholesterol with sarcopenia in patients with chronic obstructive pulmonary disease p. 327
Walid Abu-Libdeh, Jeneen Khrais, Laith Suwan, Fares Hamdan, Ahmad Qandil, Aya Abdelfattah Kaml, Ghaith Alsabbagh, Said Alsaied, Mohamed Feras Ebedin, Sahar O Aburuf, Manahil A Bakir, Razan A Awad, Fadwa B Yasin, Tahir Muhammad, Rizwan Qaisar
DOI:10.4103/ijrc.ijrc_62_22  
Background: Plasma high-density lipoproteins-cholesterol (HDL-C) is a marker of metabolic health; however, its association with age-associated muscle loss, termed sarcopenia, is unknown. We evaluated the clinical importance of HDL-C in predicting sarcopenia in patients with chronic obstructive pulmonary disease (COPD). Methods: We investigated male healthy elderly and COPD patients, 54–79 years old (n = 55–59/group) through clinical examination, laboratory investigation, and spirometry. Sarcopenia was evaluated as low handgrip strength (HGS), appendicular skeletal mass index (ASMI), and gait speed. Enzyme-linked immunosorbent assays were used to measure the circulating markers of inflammation (C-reactive protein [CRP]) and oxidative stress (8-isoprostanes). Results: The COPD patients exhibited reduced HGS, ASMI and gait speed, and higher CRP and 8-isoprostanes levels and incidence of sarcopenia than controls (all P < 0.05). Plasma HDL-C levels exhibited significant correlations with CRP, HGS, and 8-isoprostane levels (all P<0.05) but not with ASMI and gait speed in both cohorts. Additionally, plasma HDL-C was an independent predictor of sarcopenia in controls and COPD patients (AUC = 0.631, P<0.05). Conclusion: Altogether, our data show that plasma HDL-C levels are a valuable marker of muscle decline and sarcopenia in healthy elderly and patients with COPD.
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Epidemiological and clinical features of COVID-19 in elderly patients: A cross-sectional study p. 333
Bidhata Khatri, Kena , Shantha Kumari, KK Shyamala, Usha
DOI:10.4103/ijrc.ijrc_63_22  
Background: Elderly population represents the most vulnerable group with increased risk of developing severe COVID-19 infection and high mortality. More research is needed in understanding the complexity of disease due to limited data as only few studies have been conducted till date in India. Objectives: This study aimed to identify the epidemiological and clinical features among elderly population with COVID-19 infection at a tertiary care center, south India. Materials and Methods: A prospective, cross-sectional study was conducted among reverse transcription-polymerase chain reaction (RT-PCR)-confirmed COVID-19 elderly patients ≥60 years admitted at a tertiary care center in south India from June 2021 to August 2021 after the institutional ethical committee clearance. Their demographic and clinical data were collected and analyzed. Results: A total of 32 RT-PCR–confirmed patients of age ≥60years were included. Majority (62.5%) of them were in the age group of 60–70 years, and the mean age was 70.25 ± 5.68 years. Females were predominant. Severe infection was found in 31.25% of the patients, and 56.25% had moderate infection. Hypertension (43.75%) was the predominant comorbidity followed by diabetes mellitus (34.37%). Cough (82%), dyspnea (70%), and fever (63%) were the most common presenting symptoms. The mean duration of symptoms to hospitalization was 4.7 ± 2.09 days, with majority of patients presenting bilateral lung involvement. Conclusion: There is high prevalence of COVID-19 in the age group of 60–70 years, predominantly female patients. Cough and dyspnea are common presenting symptoms. Hypertension and diabetes are major comorbidities. Most patients presented with bilateral lung involvement and longer duration of symptom onset to hospitalization. High index of suspicion with preventive strategies is required for better healthcare in elderly patients.
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Analysis of peak expiratory flow rate and spirometry in obese and nonobese schoolchildren p. 337
Gayathri Raji, Kishore Kumar, Nisha Ganga, Meenakshi Narasimhan
DOI:10.4103/ijrc.ijrc_67_22  
Introduction: Obesity is a health condition of the collection of fat on the human body leading to increased body mass index and other health issues and has various impacts on the respiratory system, which reduces the functional capacity of the lung. It is also known that obesity in childhood is a serious health issue, leading to overweight for children. Pulmonary function test is an essential component for evaluating lung functions that shows valuable procedures for diagnosing and managing respiratory diseases. Materials and Methods: This study was conducted on school children in the age group of 11–17-year-old obese and nonobese students. Lung function was measured using the spirometry and mini-Wright's peak expiratory flow (PEF) meter to identify differences among children. Results: A total of 245 healthy boys and girls, ranging from 11 to 17 years of age, were recruited for the study. There is no statistical difference between mean spirometric values of forced vital capacity (FVC), forced expiratory volume in the first (FEV1), FEV1/FVC %, FEF 25%–75% and PEF rate for obese groups in comparison with the nonobese control group. Conclusion: The current study found that females have lower lung function than males, which is significant statistically (P < 0.03) and to overcome respiratory illness.
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A cross-sectional descriptive study to ascertain factors influencing delay in diagnosis among newly diagnosed pulmonary tuberculosis patients p. 341
Nithin Thomas, Ragulan Rajalingam, Viswambhar Vallabhaneni, Jereen Varghese
DOI:10.4103/ijrc.ijrc_74_22  
Introduction: Tuberculosis (TB) is a communicable disease. The management, as well as the outcome, depends upon the early detection and diagnosis of the disease. Delay in diagnosis leads to worsening of the patient's condition as well as the emergence of multi-resistant bacilli. Objectives: The objectives were to know how many persons had diagnostic and treatment delays, as well as the factors that were linked to delayed care-seeking (patient delay) and diagnosis by health-care professionals (health-care system delay) among newly diagnosed pulmonary TB patients. Methodology: A cross-sectional study of 115 diagnosed pulmonary TB patients was done. The time between the initial symptoms and the first encounter with a hospital institution was referred to as the patient's delay. The time between first contact with a health-care facility and diagnosis confirmation was referred to as the diagnostic delay. A cutoff threshold of 4 weeks was used to determine the diagnostic delay. A patient delay of more than 2 weeks and a health-care system delay exceeding 2 weeks were also evaluated. Results: In this study, 94 (81.7%), 69 (60%), and 100 (87%) subjects had patient, health system, and diagnostic delays, respectively. Conclusion: The majority of the participants in the study experienced a diagnostic delay, followed by patient and health-care system delays. The educational status, income status, distance to a health care facility, cost, initial consultation with the type of health-care personnel in the health-care system, and frequency of consultations were associated with the delays.
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Pulmonary hypertension in posttubercular pulmonary fibrosis: A prospective study from Western Himalayas p. 349
Sanjay Kumar, RS Negi, Sunil Sharma, Arvind Kandoria, Trilok Chand Guleria
DOI:10.4103/ijrc.ijrc_83_22  
Introduction: Pulmonary tuberculosis (PTB) has been linked to a high rate of morbidity and mortality. Studies that assessed the impact of treated PTB as a cause of disability have focused on impairment of pulmonary function. Pulmonary hypertension (PH) must be assessed in patients with posttubercular pulmonary fibrosis. The goal of this study was to use Doppler echocardiography to determine the prevalence of PH in individuals with posttubercular pulmonary fibrosis. Materials and Methods: It was a prospective cross-sectional hospital-based study carried out over a period of 1 year. Patients having posttubercular pulmonary fibrosis were enrolled after fulfilling the inclusion and exclusion criteria, further evaluated by Doppler echocardiography for PH. Results: A total of 80 patients with the most common age group of 31–40 years and female predominance were involved in the study. Dyspnea was the most common symptom being reported by 100% of the patients, followed by cough (32.5%), hemoptysis (22.5%), chest pain (10%), and syncope (2.5%). Tricuspid regurgitation velocity was found <2.8 m/s in 52.5%, between 2.9 and 3.4 m/s in 30% and >3.4 m/s in 17.5% patients. In our study, mild PH was present in 25%, moderate PH in 6.3%, and severe PH in 16.3% of patients with an insignificant P = 0.200. Conclusions: Tuberculosis may have a causal association with PH. The results of the present study suggest that 2D echocardiography is a useful tool in diagnosing pulmonary hypertension in posttubercular pulmonary fibrosis.
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Prevalence and predictors of osteoporosis in patients of interstitial lung disease: An observational study from North India p. 353
Deepak Aggarwal, Anshu Palta, Rohit Jindal, Anuj Kumar, Mandeep Kaur Sodhi, Varinder Saini
DOI:10.4103/ijrc.ijrc_86_22  
Background: Osteoporosis has been widely reported in chronic respiratory diseases such as chronic obstructive pulmonary disease and cystic fibrosis. However, there is a scarcity of data on its prevalence and risk factors in interstitial lung disease (ILD), particularly in Indian patients. Aims: The present study was conducted to determine the prevalence and predictors of osteoporosis in ILD patients. Materials and Methods: We conducted a cross-sectional study, in which ILD patients presenting to the hospital were enrolled. After collecting demographic and clinical data, the patients underwent a dual-energy x-ray absorptiometry scan of the femoral neck to measure bone mineral density. Osteoporosis was diagnosed based on their T-scores, following the World Health Organization guidelines. Univariate and multivariate logistic regression analyses were performed to determine the risk factors of osteoporosis in ILD. Results: The mean age of the 97 ILD patients was 55.7 + 12.6 years (range 28–84 years) with the predominance of females (n = 61). Osteoporosis was detected in 39 (40.2%) patients. Female gender, duration of symptoms, and low hemoglobin level had a positive association with osteoporosis on univariate analysis (P < 0.05). However, duration of symptoms (adjusted odds ratio [OR]-1.29; 95% confidence interval CI-1.02–1.63; P = 0.04) and hemoglobin level (adjusted OR-0.59; 95% CI-0.39–0.89; P = 0.01) were the independent risk factors of osteoporosis on multivariate analysis. Conclusion: Osteoporosis is common comorbidity seen in ILD patients. A longer duration of ILD symptoms and low hemoglobin level can predict the presence of osteoporosis in these patients.
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Lung cancer diagnosis by bronchoscopy at tertiary care center: A retrospective analysis p. 358
Keyur Mayankbhai Patel, Bhavikkumar Ashokbhai Chauhan, Nalin T Shah
DOI:10.4103/ijrc.ijrc_92_22  
Introduction: Lung cancer stands second ranked among all cancers with an incidence of 11.4% worldwide. In India, it remains the fourth-most common cancer with an incidence of 5.5% and mortality of 7.8%. The surveillance, epidemiology, and end results (SEER) database is used by the American Cancer Society to access survival rates for various cancer types. Five-year survival of nonsmall-cell lung cancer and small-cell lung cancer by SEER stages is ranging from 8% to 64% and 3% to 29%, respectively, majorly influence by the spread of cancer. Objectives: To study the demography of lung cancer and establish the utility of bronchoscopy in lung cancer diagnosis. Materials and Methods: A retrospective observational study was carried out on patients having radiologically proven lung mass in the period of November 2017 to October 2020. Results: A total of 416 patients, had a mean (standard deviation [SD]) age of 58.1 (10.1) years, including 83.7% males. Most were smokers (79.8%) with a mean (SD) smoking index of 506.45 (252.16). The most common types of lung cancer in descending order were adenocarcinoma (ADC) (43.8%), squamous cell carcinoma (34.9), small-cell lung cancer (12%), and others (9.3%). Upper lobe involvement (46.8%) was more common. At the time of diagnosis, 72.6% of total patients were presented with a stage III or higher index of severity. The yield of endobronchial biopsy, bronchoalveolar lavage, transbronchial lung biopsy, transbronchial needle aspiration, and brushing were 87.8%, 45.5%, 64.1%, 53.2%, and 45.1%, respectively, with overall diagnostic yields of 69.9%. Conclusion: Lung cancer is mainly discovered in the elderly, males, and smokers with advanced pathological stages. The most common morphology of lung cancer is ADC. Bronchoscopy is considered an initial tool for the assessment of lung mass and shows a higher diagnostic yield in centrally located tumors.
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Survey on analysis of knowledge, attitudes, and Belie's regarding COVID-19 vaccination in the selected Region of North Maharashtra: A cross-sectional study p. 363
Gaurav Shriram Patil, Dinesh Dattatraya Borhade, Bhupesh Digambar Patil, Sopan Namdev Nangare, Ganesh Bansi Patil
DOI:10.4103/ijrc.ijrc_100_22  
Background: Since the beginning of the COVID-19 pandemic, several vaccines have been approved for use and are being distributed globally in various regions. Still, general public knowledge, attitudes, and belief toward COVID-19 vaccination are poorly understood. As a result, the present study aimed to investigate community knowledge, attitudes, and beliefs towards COVID-19 vaccination in North Maharashtra. Materials and Methods: An exploratory and anonymous general population-based Google survey was conducted among 358 participants (64%: 229) male and (36%: 129) female. A descriptive, cross-sectional survey using the Snowball sampling technique was used as a tool for experimentation whereas statistical data analysis was performed using descriptive statistics to determine the variables predicting knowledge, attitudes, and beliefs towards COVID-19 vaccination. Results: As a result, 91.9% of participants were fully informed about the COVID-19 vaccine's development. Around 69.6% of participants experienced that a booster dose of the COVID-19 vaccine may not be proven harmful to the human being. In addition, 79.6% of study individuals were confident that the situation of COVID-19 would be under control after adequate vaccination. As well, 88.5% of participants considered that vaccines strengthen the immune system of an individual. Conclusion: In summary, the findings reflect a better knowledge and more encouraging attitude of participants regarding COVID-19 vaccination in the selected region of North Maharashtra.
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Effect of COVID-19 on tuberculosis care in a District of Western Gujarat p. 369
Hymn Parikh, Nikita Savani
DOI:10.4103/ijrc.ijrc_105_22  
Introduction: COVID-19 has had a devastating and disrupting effect on all health-care services across the globe, but tuberculosis (TB) services have been disproportionately affected. Downfall trend of TB notification, diagnosis, and treatment due to the COVID-19 pandemic in our district study was carried out. Aim: To assess COVID-19 effects on TB care during 2020-2021. Methodology: A cross-sectional study design comprising a secondary analysis of an existing dataset was carried out. Data on the total number of cases notified, diagnosed, and drug susceptibility in drug resistance and sensitivity were collected for 2020 and 2021. Result: A statistically significant difference in drug-resistant and drug-sensitive cases was observed during the first and second half of 2020 (P < 0.001). In 2021 similar to the earlier wave, there was a decline in case notification during the peak of the pandemic. Conclusion: We assessed that during COVID-19, TB care significantly plummeted in our district; however, with the rapid response plan gradually, there was a rise seen in TB notification, diagnosis, and treatment services.
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Timed up and go test: An underutilized tool in patients with chronic respiratory disease p. 373
Nikita Kulsange, Mariya Prakash Jiandani
DOI:10.4103/ijrc.ijrc_110_22  
Background: Patients admitted with chronic respiratory diseases (CRDs) find it difficult to return to their day-to-day activities postdischarge due to muscle dysfunction and cardiorespiratory load. The Timed Up and Go (TUG) test is extensively used for predicting falls; however, it is underutilized to assess the cardiorespiratory load. The study was designed to assess the time in seconds, the cardiorespiratory load including desaturation with TUG, and also the correlation if any between TUG time in seconds with oxygen saturation (SpO2) and Barthel Index score. Materials and Methods: Hundred and twenty-eight patients admitted with CRDs in the age range of 40–70 years were included. Activities of daily living were scored on Barthel Index. TUG was carried out and changes in cardiorespiratory parameters, i.e., heart rate (HR), blood pressure (BP), respiratory rate (RR), and SpO2 were noted. Results: All cardiorespiratory parameters HR, BP, and RR showed a statistically significant change (P < 0.0001). There was a significant drop in SpO2 (mean 9%) post TUG. There was a significant but weak inverse correlation (r = 0.5069) observed between TUG in seconds and SpO2 at rest. There was no correlation between TUG and Barthel score. The mean time for TUG was 16.73 ± 3.11 s indicating a moderate risk of fall. Conclusions: TUG leads to a significant change in cardiorespiratory parameters including SpO2. It can be used as a test to assess activity tolerance and the need for oxygen supplementation.
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Respiratory therapy students' perception toward their career and level of satisfaction with the learning resources: A cross-sectional survey result from India Highly accessed article p. 378
Jithin K Sreedharan, Udaya Kumar Rao, Mohammed Al Ahmari, Sashidhar M Kotian, Praveen Beekanahalli Mokshanatha
DOI:10.4103/ijrc.ijrc_127_22  
Background: A structured respiratory care (RC) program has a greater impact on student's critical thinking and problem-solving. Across India, the RC curricula differ in structure and duration. With the exception of a few well-established central universities and autonomous institutions, many required appropriate educational resources and qualified faculty. The objective of the current study is to determine RT students' perception toward their careers and level of satisfaction with the available learning resources. Materials and Methods: In this cross-sectional survey, 904 respiratory therapy students participated from medical universities and educational institutions across India. Institutional Ethics clearance was obtained from the host institution and students were given basic information regarding the survey. A validated, structured questionnaire was used which consists of 26 questions that cover four domains: Perception (4 items), satisfaction (13 items), curriculum (5 items), and suggestion (4 items). The questions were answered as per the five-point Likert scale. Data analysis was descriptive, and logistic regression was performed to evaluate factors associated with students' satisfaction with the learning resources. Results: The majority of the respondents were female (59%) and belonged (48%) to the age group of <22 years. 92% of them are pursuing bachelor's degree in RC. Most respondents are satisfied with the practical and theoretical training (69%), quality of teaching (70%), the infrastructure available (69%), and the skill level of the faculties (80%) at their institutions. Most respondents (83%) believed that there is no adequate recognition for respiratory therapists (RTs) in India and 90% of the respondents were in fact planning to move overseas to seek job opportunities. Moreover, 86% of respondents believed that there is an urgent need for establishing a regulatory body for the RT profession. Conclusion: The respiratory therapy students believe that there is no adequate recognition for RTs in India and a vast majority of them want to go abroad to seek job opportunities. A proper regulatory body for RT would help in standardizing both the academic and clinical aspects of the RT profession, along with improving job opportunities for RTs in the future.
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CASE REPORTS Top

Spontaneous hemothorax in a patient of ruptured ectopic pregnancy p. 386
Bishakha Swain
DOI:10.4103/ijrc.ijrc_111_22  
Hemothorax is a condition characterized by the accumulation of blood within the pleural cavity. Most hemothoraces result from direct trauma, blood vessel rupture, tumor, or iatrogenic complication. Rarely, a hemothorax results from a medical condition such as pulmonary embolism or rupture of an aortic aneurysm. Here, we report an atypical case of hemothorax in a 24-year-old female following hemoperitoneum secondary to a ruptured ectopic pregnancy who had neither amenorrhea nor per vaginal bleeding. She underwent a laparotomy and was operated on for a ruptured right tubal ectopic. Hemothorax was diagnosed postoperatively – which had possibly developed through diaphragmatic fenestrations – and managed with a chest drain.
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Hodgkin's lymphoma in a milky way p. 389
Hasna Erattengal, C Nandish
DOI:10.4103/ijrc.ijrc_120_22  
Chylothorax refers to the accumulation of chyle in the pleural space. The most common cause of nontraumatic chylothorax is tuberculosis, malignancy, and congenital causes. We share a case of bilateral chylothorax in a 24-year-old male patient admitted with complaints of fever, dry cough, and dyspnea, initially suspected of tuberculosis. The effusion was drained, and a biochemical test revealed chylothorax. Chest radiograph showed widening of mediastinum. Contrast-enhanced computed tomography done revealed lobulated anterior and superior mediastinal mass lesion possibility of lymphoma. Excision biopsy of the lymph node was done, and the biopsy report revealed histological features consistent with the malignant lymphoproliferative process in favor of the nodular sclerosis variant of classic Hodgkin's disease. This case reveals bilateral chylothorax as the first manifestation in a young male patient of Hodgkin's lymphoma. Early suspicion and systematic diagnosis provide good outcome.
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Airleak syndrome like spontaneous subcutaneous emphysema, pneumomediastinum and pneumothorax as presenting signs of Corona virus pneumonia - a case series p. 392
Sanjeev Kumar Singla, Rakendra Singh
DOI:10.4103/ijrc.ijrc_124_22  
Spontaneous subcutaneous emphysema, pneumothorax, and pneumomediastinum are rare entities as the initial presentation of coronavirus infection in patients without positive pressure ventilation. This case series presents five cases of COVID-19 pneumonia who presented with alveolar air leak syndrome without prior invasive or noninvasive ventilation and high-flow nasal cannula oxygenation. Two patients presented with surgical emphysema, two with pneumothorax, and one with pneumomediastinum. This series included 30–50-year-old nonsmokers (three males and two females) with no previous history of any comorbidity and smoking who came to the emergency with symptoms such as cough, breathing difficulty, and respiratory distress. The COVID-19 infection was diagnosed by reverse transcriptase-polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2. Chest X-ray and computed tomography showed diffuse multifocal ground-glass infiltrates, interlobular septal thickening, and infiltration in all patients. Three patients had subcutaneous emphysema, two had pneumothorax and pneumomediastinum, and one had pneumomediastinum. Three patients later on required invasive mechanical ventilation. Alveolar air leak syndrome including spontaneous pneumomediastinum, pneumothorax, and subcutaneous emphysema is rarely seen as the initial presentation of coronavirus pneumonia but may develop after positive pressure ventilation.
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SHORT COMMUNICATION Top

Public health interventions to minimize the impact of chronic obstructive pulmonary disease p. 396
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_117_22  
Chronic obstructive pulmonary disease (COPD) is one of the most frequent, preventable, and manageable lung diseases that results due to the narrowing of small airways. Owing to the tiredness and breathlessness linked to the disease, the individuals fail to work to their potential in both workplace and home settings, and thus, it poses a financial load on the family. Even though there is no cure for the disease, strategies to promote early diagnosis and initiate appropriate treatment are crucial to arrest not only the progression of the disease but also minimize the risk of exacerbation of the disease. There is a definite need to create awareness about the condition among the general population, the potential risk factors, treatment modalities, the significance of self-care, and the services available in health-care establishments. To conclude, COPD is a global public health concern that has been linked to morbidity, impairment of quality of life, and mortality. It is high time that specific measures are taken to minimize the impact of the disease on the affected individuals, family members, and health-care establishments.
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LETTER TO EDITOR Top

Mortality at the Kedarnath pilgrimage trek in 2022: A possible interplay between post-COVID syndrome and high-altitude mountain sickness p. 398
Nidhi Uniyal, Yashendra Sethi
DOI:10.4103/ijrc.ijrc_119_22  
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