Chemotherapy versus best supportive care in the management of lung cancer

This study was planned to evaluate the role of chemotherapy in improving survival in patients with inoperable lung cancer. Seventy eight patients with histologically proven lung cancer were followed up for a period of one year. Thirty eight out of them received chemotherapy and 40 patients received supportive care only. Main outcome measure was survival from the date of diagnosis. The patients receiving chemotherapy had a median survival of 23.2 weeks compared to that of 10.1 weeks in patients receiving best supportive care. Among patients with non-small cell lung cancer, median survival was 27.0 weeks in chemotherapy group and 10.3 weeks in supportive care group. Patients who received cisplatin plus docetaxel combination had a better survival than those who received MIC (mitomycin, ifosfamide, cisplatin) combination. Patients with good performance status benefited more from chemotherapy, although patients with poorer performance status also had significant improvement in survival with chemotherapy. In conclusion, chemotherapy results in a modest, but significant improvement in survival in patients with inoperable lung cancer compared to best supportive care alone.

Surfactant protein-A levels in patients with acute respiratory distress syndrome

BACKGROUND & OBJECTIVES

The decrease in surfactant protein-A (SP-A level) has recently been implicated in the pathophysiology of acute respiratory distress syndrome (ARDS). Mechanical ventilation is the main modality of treatment of ARDS. But information on the SP-A levels after mechanical ventilation is scanty. We therefore studied the effect of mechanical ventilation on SP-A levels in patients with ARDS.

METHODS

In a prospective, observational study conducted in the Respiratory Intensive Care Unit of a tertiary care hospital in north India, 13 patients with ARDS requiring mechanical ventilation were included. SP-A levels in the bronchial aspirates were serially estimated by ELISA at the start of mechanical ventilation and after 24 and after 48 h.

RESULTS

The SP-A level at the start of mechanical ventilation was 3.06 +/- 2.56 microg/ml. The levels gradually increased to 3.99 +/- 2.39 and 6.64 +/- 2.72 microg/ml, at 24 and 48 h respectively, and this increase was statistically significant (P < 0.05). Patients having an infectious etiology had lower SP-A levels compared to those with non-infections causes. Neither the initial SP-A level nor the increase in SP-A level correlated with the improvement in lung function or duration of ventilation.

INTERPRETATION & CONCLUSION

The present study showed a progressive increase in the SP-A levels in patients with ARDS on mechanical ventilation. Further studies are required to confirm that the increase in SP-A levels may be one of the contributors for recovery in ARDS.

Surfactant protein-A in lung lavage fluid obtained from patients with idiopathic pulmonary fibrosis

BACKGROUND

Alterations in surface-active material may contribute to the pathogenesis of idiopathic pulmonary fibrosis both by increasing the elastic recoil due to surface forces and by promoting alveolar collapse. This study intends to evaluate the surfactant protein-A levels in bronchoalveolar lavage in patients of idiopathic pulmonary fibrosis.

MATERIAL AND METHODS

Ten patients of idiopathic pulmonary fibrosis (IPF) of either sex were taken up for estimation of surfactant protein-A (SP-A) levels in bronchoalveolar lavage. The final diagnosis of IPF was based on histopathology and high resolution CT. Ten controls were taken out of which five patients were histopathologically proven cases of sarcoidosis and five patients with normal chest X-ray and CT scan. History, physical examination and routine investigations were done to rule out any concomitant illness.

RESULTS

Age range of patients varied from 37-65 years (mean +/- SD of 50.65 +/- 9.05) and controls 30-62 years (42.50 +/- 9.95). Fiberoptic bronchoscopy and bronchoalveolar lavage was carried out and fluid aspirated was studied for surfactant protein-A. The level of surfactant protein-A recovered was lower in patients with idiopathic pulmonary fibrosis in comparison to control group p < 0.01 (1.86 +/- 1.26 and 5.76 +/- 2.0 microg/ml respectively). The levels of surfactant protein-A also revealed that the level decreased with derangement of pulmonary function.

CONCLUSIONS

The study thus showed that the level of surfactant protein A is reduced in patients with idiopathic pulmonary fibrosis. It is likely that they have a significant role in pathogenesis of idiopathic pulmonary fibrosis and its progression. Surfactant-A may have important therapeutic implications. Further studies are required for a definite answer.

Eight-year study of allergic bronchopulmonary aspergillosis in an Indian teaching hospital

A total of 651 patients with clinically suspected allergic bronchopulmonary aspergillosis (ABPA) were evaluated during the 8-year period from January 1991 to December 1998. Overall, 338 cases (51.9%) were positive either by sputum microscopy/culture (66 of 203 patients), by skin reactivity (150 of 309 cases), or by precipitating antibodies (122 of 338 patients) against Aspergillus species. However, in 89 patients, diagnosis of ABPA was confirmed on the basis of Rosenberg's criteria. Clinical profile and laboratory findings of those patients were analysed. The disease was found to be more common among males. Poor control of asthma, constitutional symptoms, mucopurulent expectoration, increased dyspnoea and wheezing and rhonchi were the main presenting features. Skin reactivity against aspergillin was seen in 73 (82%), precipitating antibodies against Aspergillus species were positive in 64 (72%) and sputum microscopy/culture was positive in 56 (63%) of those 89 patients. Central bronchiectasis and fleeting shadows were the most common radiological findings. This study highlights the importance of ABPA in north India and draws attention to the need for further analysis of criteria to use in the diagnosis of patients with ABPA.

Intensive respiratory care in patients with myasthenic crisis

Six patients received mechanical ventilation for 8 episodes of myasthenic crisis in a two year period. Median duration of ventilation was 8 days. Only one patient required ventilation for more than three weeks and underwent tracheostomy. Atelectasis and pneumonia were the common ventilator associated complications observed, and these responded to therapy. Two patients underwent thymectomy after initial stabilization and while being ventilated. All patients recovered completely.

Hepatitis B and C virus--prevalence and prevention in health care workers

BACKGROUND

Hepatitis B and C viruses are important causes of liver related morbidity and mortality. We aimed at determining the presence of hepatitis B and C virus infections in the health care workers (HCWs) and their compliance for the HBV vaccination.

METHODS

Three thousand five hundred and fifty six health care workers were screened for HBsAg and 115 for anti-HCV by ELISA. HBsAg negative individual were offered HBV vaccination and record of their compliance was kept. Anti-HBs titers were determined one month after 2nd or 3rd dose of vaccine in 273 subjects.

RESULTS

Out of 3556 health care workers, 61 (1.7%) were found to be positive for HBsAg. One out of 115 HCWs (0.87%) was found to be positive for anti-HCV. Fifteen percent of HCWs received only one dose, 26% received two doses 59% received three doses and 2.5% also received the booster dose of the HBV vaccine. All those tested had anti-HBs titers more than 10 mUI/ml.

CONCLUSION

In HCWs, HBsAg and anti-HCV prevalence was found to be 1.7% and 0.87% respectively. HCWs in our hospital, despite the awareness on HBV and HCV infection are noncompliant for HBV vaccination.

A comparison of non-tapering vs. tapering prednisolone in acute exacerbation of asthma involving use of the low-dose ACTH test

OBJECTIVE

To determine if there is a difference in early relapse rates and adrenal suppression between patients receiving an 8-day course of 40 mg/day prednisolone and those receiving an 8-day tapering course of prednisolone.

METHODS

This was a prospective, randomized, open clinical trial conducted in a tertiary care center. All asthmatic patients with exacerbation who were judged well enough for discharge home from the emergency department were eligible for participation. Patients with a history of chronic obstructive pulmonary disease, congestive heart failure, pneumonia, pneumothorax, or other pulmonary process and asthmatics already using inhaled or oral steroids within 2 weeks of admission to the emergency department were excluded. Patients on discharge were administered either on 8-day course of 40 mg/day prednisolone or an 8-day tapering course of prednisolone (tapering from 40 mg to 0 mg). Patients were asked to return on Day 12 for cosyntropin stimulated test and pulmonary function testing and on Day 21 for pulmonary function testing only.

RESULTS

A group of 13 patients treated with non-tapering course (40 mg/day) of prednisolone for 8 days were compared to a group of 13 patients treated with a tapering course (40 mg taper by 5 mg/day) for 8 days. There were no differences in the FEV1 percent predicted (Days 12 and 21), the incidence of relapse, or the incidence of adrenal suppression between the 2 groups.

CONCLUSION

In this small study, we found no significant difference in relapse rate or adrenal suppression between asthmatics receiving an 8-day tapering dose of prednisolone and those receiving 40 mg/day prednisolone upon discharge from the emergency department.

Oxidative burden and antioxidant defense system in polymorphonuclear leukocytes of human lung diseases

Superoxide anion (O2.-) and hydrogen peroxide (H2O2) production was significantly higher in blood neutrophils (PMNs) of patients with lung cancer and non-malignant lung diseases when compared to the controls (p<0.001). Superoxide dismutase (SOD) activity was significantly decreased in PMNs of patients with lung cancer (p<0.001). Similarly, catalase and glutathione peroxidase (GPx) activities were lower in PMNs of lung cancer patients as compared to non-malignant lung diseases and controls. There was an increase in HMP shunt activity as measured by rate of formation of 14CO2 from [1-14C]-glucose in PMNs of lung cancer patients. Modifications in the antioxidant defense system in PMNs of malignant and nonmalignant lung diseases, the changes being more in the malignancy are indicated.

Radiographic patterns in lung cancer

Three hundred seventy three previously diagnosed patients with lung cancer, attending the Lung Cancer Clinic at this institute were studied. Chest radiographs were interpreted in all cases. Radiography was compared in different cell types. Squamous cell carcinoma 158 (42.4%), followed by small cell lung cancer 122 (32.7%), was the commonest histological subtype. Upper zone was involved in maximum number of cases 158 (42%), followed by mid zone 122 (32.7%), lower zone 60 (16%) and the entire lung 33(8.8%). Adenocarcinoma presented as a peripheral mass in 37 (61%) cases and in 23 (38.3%) as a central lesion. Presentation as a central mass (114, 72.2% cases) was more common among squamous cell carcinoma than as a peripheral lesion (44, 27.8% cases). Similarly, small cell cancer also presented more commonly as a central lesion (102, 83.6% cases) than as a peripheral lesion (20, 16.4% cases). Isolated pleural effusion was present in 3.8% in squamous cell lung cancer, 22% in adenocarcinoma and only 4% in small cell lung cancer.

Nitric oxide derivative in bronchoalveolar lavage fluid from patients with idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis is a chronic inflammatory disorder of unknown aetiology with a number of inflammatory cells playing a role in its pathogenesis. In this study, we have attempted to find out the possible role of nitric oxide in its pathogenesis by way of measuring the nitrite and nitrate levels in the bronchoalveolar lavage fluid. Ten patients of histologically proved idiopathic pulmonary fibrosis and 10 controls (5 with normal chest skiagrams and 5 with sarcoidosis) were included in the study Bronchoalveolar lavage was carried out in these cases. The levels of nitrates and nitrites were increased in cases of idiopathic pulmonary fibrosis (0.77+/- 0.36 and 8.93 +/- 2.63 nmol/mg of protein) compared to those in controls (0.38 +/- 0.06 and 3.80 +/- 1.11, respectively for sarcoidosis patients); (0.39 +/- 0.13 and 6.56 +/- 1.61 for subjects with normal chest skiagrams). These differences were statistically significant (p < 0.05 to 0.01). These findings suggest a possible role of nitric oxide in the pathogenesis of idiopathic pulmonary fibrosis.

Inflammatory pseudotumour of the lung : report of a case and review of literature

A case of unusual benign tumour of the lung is described. The patient presented with a history of prolonged cough with expectoration, and fever with generalised weakness of shorter duration. Radiological examination of the chest revealed a large non-homogeneous opacity with calcification in the left lower zone. Fine needle aspiration cytology (FNAC) was inconclusive. Therefore, surgical exploration and a left lower lobectomy was performed. The diagnosis of inflammatory pseudotumour was made on histopathological examination.

Pneumocystis carinii pneumonia in a patient with active untreated systemic lupus erythematosus

Pneumonias due to Pneumocystis carinii (PCP) commonly occur in immunocompromised hosts. Although a treatable infection, it is associated with high mortality. A case of PCP presenting in an untreated case of systemic lupus erythematosus is reported, in view of the rarity of this association.

Management of respiratory failure in severe neuroparalytic snake envenomation

Fourteen patients with severe neuroparalytic snake envenomation, resulting in acute type II respiratory failure, admitted to respiratory critical care unit for mechanical ventilation during one year period, were studied. Ventilatory requirements, amount of anti snake venom (ASV) infused, period of neurological recovery and hospital survival were evaluated. All patients had severe manifestations such as ptosis, extraocular muscle paresis and limb weakness along with dyspnoea. Seven patients (50%) had additional complaints of dysphagia and dysphonia. ASV was administered to all, with a median requirement of 900 ml. Mechanical ventilation was required for a median duration of 17 hours and all except one patient, who had suffered irreversible hypoxic cerebral injury prior to resuscitation, survived with complete neurological recovery. We conclude, that the timely institution of ventilatory support and anti-venom therapy in such patients, is associated with an excellent outcome.

Effect of exposure to domestic cooking fuels on bronchial asthma

The effect of indoor air pollution due to domestic cooking with biomass fuel and liquefied petroleum gas (LPG) on the course of bronchial asthma was examined in one hundred non-smoking female asthmatics. The parameters for evaluation were symptoms, emergency visits, and drug requirements. The patients also measured peak expiratory flow rate (PEFR) at home five times daily over a period of one week and the levels of carboxyhaemoglobin (COHb) were estimated randomly during clinic visits. The COHb levels (%) were 4.1 +/- 0.9 and 3.5 +/- 0.6 in the two groups with 22-30% of the subjects reporting increased symptoms during cooking. The number of emergency admissions and the daily requirement of steroids were comparable in both the groups. The PEFR values were lower than the predicted values in both the groups at all times. Further, the readings after exposure to cooking fuels were lower than those before cooking in both the groups (p < 0.01) and these values were similar to those observed during early morning records at 6 AM, which were the lowest. It was concluded that exposure to biomass fuel and LPG affect pulmonary function (PEFR) in asthmatics and both types of fuels affect the airway function and symptoms of bronchial asthma in a similar manner.

Aggressive atropinisation and continuous pralidoxime (2-PAM) infusion in patients with severe organophosphate poisoning: experience of a northwest Indian hospital

OBJECTIVE

The aim of the study was to find whether continuous pralidoxime (2-PAM) infusion along with aggressive atropinisation improves the outcome in patients with severe organophosphate poisoning who require assisted ventilation.

METHODS

Sixteen patients admitted to the respiratory intensive care unit (RICU) with severe organophosphate poisoning and requiring assisted ventilation were included in the study. The compounds involved were phorate (six), dichlorvos (four), oxydimeton methyl (one), monocrotophos (one), methyl parathion (one) and in three it was unknown. After decontamination, they were given intravenous (iv) bolus atropine 5 mg at onset and then 2.5 mg every 5-10 min till atropinisation was achieved, and then maintained either by intermittent bolus doses or by continuous infusion if the required dose was large. They were also given continuous iv infusion of 2-PAM in dose of 7.5 mg/ kg body weight/h (maximum 500 mg/h) after an initial bolus dose of 2 g.

RESULTS

The mean (+/-S.D.) dose of atropine was 735.02 +/- 742.98 mg (range 85-3000 mg) with maximum dose on day 1. The mean (+/-S.D) duration of 2-PAM infusion was 96.4+/-49.4 h (range 10-216 h). The mean (+/-S.D) duration of mechanical ventilation (MV) was 131.5 +/- 95.65 h (range 4-336 h). Fourteen patients could be successfully extubated and two died of bronchopneumonia and sepsis (mortality 12.5%).

CONCLUSION

Continuous 2-PAM infusion along with aggressive atropinisation after initial decontamination improved the outcome but not the duration of MV in severely intoxicated patients with organophosphate compounds who required assisted ventilation in this case series.

Interferon-gamma 1b: impact of new indications (idiopathic pulmonary fibrosis)

Idiopathic pulmonary fibrosis (IPF) is a relentlessly progressive disease with inadequate response to conventional treatment with corticosteroids and/or immunosuppressive agents in most patients. Interferon-gamma (IFN-gamma), an antifibrotic agent, has been proposed as a novel therapeutic approach. Several investigators have shown a relative decrease in systemic and pulmonary IFN-gamma activity in patients with IPF. Experimental evidence from animal and human studies also suggests that IFN-gamma administration may ameliorate lung fibrosis. Clinical experience is, however, limited to a single clinical trial that showed objective functional improvement in a small number of patients treated with IFN-gamma and low-dose corticosteroids. Further research is needed to characterise the efficacy, safety and optimum route of administration of this agent before it can be recommended for use in routine clinical practice.

Analysis of static pulmonary mechanics helps to identify functional defects in survivors of acute respiratory distress syndrome

OBJECTIVE

To assess the utility of static lung pressure-volume measurements in identifying and categorizing pulmonary function test defects in survivors of acute respiratory distress syndrome (ARDS).

DESIGN

Cross-sectional.

SETTING

Pulmonary function laboratory at a tertiary referral hospital in northern India.

PATIENTS

Six survivors of ARDS reporting for their first follow-up visit after discharge.

MEASUREMENTS AND MAIN RESULTS

Spirometry and whole body plethysmography were performed to evaluate lung volumes and to collect static lung pressure-volume data; the latter were subjected to monoexponential analysis. Three patients had a restrictive ventilatory defect as evidenced by diminished vital capacity and total lung capacity, but only one had reduced static lung compliance. The other two patients had reduced recoil pressure at total lung capacity, suggestive of respiratory muscle weakness. Two other patients with normal lung volumes had reduced static lung compliance. Exponential analysis of pressure-volume data in the three patients with reduced static lung compliance was consistent with reduced distensibility and loss of lung units in one patient each. Additionally, two patients had high values for shape constant of the exponential curve, indicative of air space distention.

CONCLUSIONS

Detailed analysis of static pressure-volume data can identify pulmonary function abnormality and categorize the dominant mechanism responsible for restrictive ventilatory defects in survivors of ARDS, even in patients with normal lung volumes. In addition to lung fibrosis, neuromuscular weakness also contributes to decline in pulmonary function.

Incidence of tuberculosis among patients receiving treatment with oral corticosteroids

OBJECTIVES

To study the incidence and pattern of tuberculosis in patients taking systemic corticosteroids (CS).

METHODS

Seventy seven patients taking oral CS for various respiratory diseases and eighty patients suffering from similar diseases but not receiving steroids were followed up for one year to study the incidence of tuberculosis.

RESULTS

Five patients (6.5%) receiving CS developed tuberculosis as against none amongst the controls (p < 0.05). Of these, three patients had sputum positive pulmonary tuberculosis and one each had sputum negative pulmonary tuberculosis and tubercular meningitis. All patients were treated with standard anti-tubercular therapy; four patients improved whereas one died due to complications of disease.

CONCLUSION

Systemic CS therapy causes a significant increase in incidence of tuberculosis.

Hypothalamo-pituitary-adrenal axis function in asthmatics taking low dose inhaled beclomethasone dipropionate

OBJECTIVES

Anti-inflammatory drugs, particularly inhaled corticosteroids remain the mainstay of treatment of bronchial asthma. However, these drugs have potential side effects. This study was undertaken to evaluate the effects of inhaled beclomethasone dipropionate (400 and 800 micrograms) over a period of six months on the hypothalamo-pituitary-adrenal axis (HPA) suppression.

METHODS

Assessment of the hypothalamo-pituitary-adrenal axis function was carried out by tetracosactrin test at time zero, (before start of treatment), three months, and six months. The baseline values served as the controls for each patient. Serum cortisol was estimated by radioimmuno assay. The response to short tetracosactrin test was classified as normal if serum cortisol levels rose at least 200 nmol/L to a minimum of 500 nmol/L.

RESULTS

There were seven patients who were inhaling beclomethasone dipropionate in a dose of 400 micrograms/day and another seven patients were taking the same drug in a dose of 800 micrograms/day. There was no side effect of the drug in any patient except in one patient who had dysphonia. The mean basal cortisol levels were normal in all the subjects at 0, 3 and 6 months of therapy. Tetracosactrin stimulation test was also normal in all patients at all the times who were receiving the dose of 400 micrograms/day. However, one patient (14%) receiving 800 micrograms/day had HPA axis suppression at six months. Two patients in this group also had low basal cortisol levels. There was no clinical evidence of such suppression/deficiency.

CONCLUSION

Beclomethasone dipropionate in a dose of 800 micrograms/day may suppress the hypothalamo-pituitary-adrenal axis if used for long periods (six months). However, this may not have any clinical significance.

Pulmonary function changes after large volume paracentesis

OBJECTIVE

To study the effect of large volume paracentesis (LVP) on pulmonary function in patients with cirrhosis of liver and tense ascites.

METHODS

Ten patients having alcoholic cirrhosis with ascites were subjected to LVP (mean 6.3 +/- 0.3 L). Pre and post paracentesis spirometry and arterial blood gas analysis were performed and compared.

RESULTS

Baseline mean lung volumes and arterial pO2 were reduced from normal predicted values. Air flow was found normal. After LVP, an increase in absolute values of vital capacity, forced expiratory flow in first second (FEV1) and peak expiratory flow was observed; only the improvement in FEV1 was significant p 0.05). Arterial pO2 also showed significant (p < 0.01) improvement after LVP.

CONCLUSION

LVP leads to improvement in measured pulmonary function.

Non invasive ventilation in COPD

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.