Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
February 2018 • VOL. 66
Abstracts : Free Papers – Platform Presentation (APICON-2018) - Respiratory System
Prevalence of ACOS Among Elderly Reporting to Emergency of a Tertiary Hospital in South India
Introduction: Asthma COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation that shares features of both Asthma and COPD. Identification of patients with ACOS in emergency is clinically important because these patients have accelerated decline in lung function, poor response to broncho-dilators.Early identification of these patients will enable early initiation of corticosteroid therapy thereby reducing emergency room visits.
Aim: To study the epidemiology of ACOS in elderly age group (>60years) presenting with obstructive airway disease to a tertiary care hospital in Bangalore.
Methods: This single centre observational study was performed in Bangalore Baptist hospital which is a tertiary care centre and NABH accredited institution. All the elderly patients (> 60years) who presented to emergency department with symptoms of obstructive pulmonary disease were evaluated using GINA/GOLD combined algorithm for diagnosis of Asthma COPD overlap syndrome (ACOS). Patients were grouped into Asthma, COPD and ACOS.
Observations: In our study of 311 patients with obstructive pulmonary disease, numbers of patients with Asthma were 99 (31%), the numbers of patients with COPD were 128 (41%) and numbers of patients with ACOS were 84 (27%). In ACOS cohort female population is higher compared to male population (35.8% vs. 21%). The mean post broncho-dilator reversibility (▲ FEV1) in patients diagnosed with ACOS was 218.6±16.3 which is in accordance with GINA/GOLD definition of ACOS. Patients identified as having ACOS were of higher mean age and more severe exacerbations when compared to Asthma or COPD group. History of Atopy is seen in 92% of patients diagnosed with ACOS. Smoking as a risk factor for ACOS is well documented in literature. In our study we found only 19% of patients with ACOS have history of smoking. We presume this disparity is because of high female population in ACOS group.
Conclusion: Prevalence of Asthma COPD overlap syndrome is 27% and patients who are diagnosed to have ACOS were sicker and have severe exacerbations when compared to Asthma or COPD alone. Our study showed the importance of past history and symptom pattern in accurate classification of obstructive pulmonary disease. However, there is a need for multi centred study to identify the true burden of ACOS in community in order to formulate a standard protocol for management of these patients.
Effect of Educational Training and Practical Demonstration on Metered Dose Inhaler Use Technique
Introduction: Incorrect use of Metered dose inhalers (MDI) is a significant barrier in improving the quality of medical care given to most patients with chronic respiratory diseases. This study was carried out in a busy medical OPD to analyze the issues pertinent to incorrect MDI use and assess the impact of a quality improvement initiative involving practical demonstration of correct technique using a standardized checklist.
Materials: This was an interventional pre and post-test study conducted in a busy medical OPD among COPD or asthma patients already on MDI. A baseline assessment of correctness of MDI use technique was done based on GINA(2011) instructions, following which a practical demonstration of correct technique was done. These patients were followed up after one month and their technique was reassessed.
Results: Total 56 patients completed the study. The mean score of MDI technique knowledge was 3.5 ±1.5, which increased to 6.7 ±1.2 after intervention (p<0.001). 27 (48.2%) patients reported having received prior educational training regarding MDI use and only 22 (39.3%) patients were using spacers.
Conclusion: Practical demonstration of correct MDI use technique using a standardized checklist reduces errors in MDI use and thus helps in quality improvement of patient care.
Diagnostic Yield of Fibre-Optic Bronchoscopy in Sputum Scarce Patients Presenting with Fever and Miliary Shadowing
Background: Miliary tuberculosisremains an elusive diagnosis to the clinician, owing to non-specific nature of clinical and radiological findings. The primary objective of this study was to study thediagnostic utility of fibreoptic bronchoscopy, including the use of BAL GeneXpertin patients presenting with fever and miliary shadowing on chest imaging.
Methodology: We conducted a prospective observational study at a tertiary care centre in New Delhi over 20 months. Thirty two treatment naïve patients with fever and miliary shadowing on chest X ray/ HRCT chest with non-productive cough were recruited into the study. They underwent a detailed clinical and relevant investigative workup. Fibreoptic bronchoscopyand related procedures likebroncho-alveolar lavage (BAL), transbronchial lung biopsy (TBLB), endobronchial lung biopsy (EBLB) and transbronchial needle aspiration (TBNA) were done as clinically appropriate in 28 patients, followed by a three month follow up.The diagnostic yield of various bronchoscopic procedures towards achieving a definitive diagnosis wasanalysed.
Results: Fibreoptic bronchoscopy yielded a definitive diagnosis in 46.4% of patients, including TB (n=9) and non-TB diagnoses (Malignancy: 3, Anthracosis:1). The overall diagnostic yield of BAL was 37%, with BAL AFB smear, GeneXpert and culture positivity (MGIT 960)in 9.1%, 27.2% and 22.7% respectively in miliary TB patients, and positive malignant cytopathology in one patient.The yield of TBLB was 28.6% (granulomata in 27.7% of miliary TB patientsand anthracosis in one patient).EBLB and TBNA enabled diagnosis of lung malignancies in three patients. The final diagnosis after follow up was TB (n=26), lung malignancy (n=3), anthracosis (n=1), silicosis (n=1) and respiratory bronchiolitis (n=1). Choroidal tubercles were seen in as many as 46.2% of miliary TB patients. Post procedural pneumothorax occurred in one patient which was managed appropriately and resolved in 48-72 hours.
Conclusion: Miliary mottling on chest imaging may occur due to many causes other than TB. Bronchoscopy and bronchoscopic procedures play an important diagnostic role in the evaluation of patients with miliary mottling on chest imaging.
Study of Glucose Disposition Index in Subjects of Obstructive Sleep Apnea Syndrome
Introduction: Obstructive sleep apnea syndrome (OSAS) is an established risk factor for diabetes mellitus. Prevalence of OSAS in Indian males and females are 2.4 to 7.5% and 1 to 2.1% respectively. Prevalence of type 2 diabetes mellitus is 30.1% in OSA patients. Hypoxia, oxidative stress & neurohumoral activation are responsible for insulin resistance and beta cell dysfunction in OSA patients. Glucose disposition index (GDI) is a surrogate marker of these two factors. So GDI may be a useful tool for predicting overt diabetes beyond fasting blood glucose and post prandial blood glucose in OSAS patients.
Materials: 50 cases ofOSAS patients, diagnosed by polysomnography (Apnea hypopnea index, AHI ≥5) were compared with 30 controls those who were low risk group as per modified berlin questionnaire. Different parameter of glycemic controls like fasting glucose, fasting insulin, 30 min glucose and insulin level after 75 gm oral glucose intake, and GDI (∆Insulin 0-30 / ∆Glucose 0-30 ×1/Fasting insulin), were measured and compared between cases and controls and also compared amongmild, moderate and severe grade of OSAS patients.
Observation: Mean age of cases and controls were 50.86±10.49 and 49.6±10.98 years respectively. Males were in majority. Mean values of GDI of controls, mild, moderate, and severe OSAS were 0.04,0.03, 0.02, and 0.01 respectively, p value <0.05.Mean values of fasting blood glucose, fasting insulin level, 30 minute blood glucose and 30 minute insulin level were significantly higher among cases than controls, p value <0.05. But after adjusting confounding factors, only GDI, 30 minute insulin and 30 minute blood glucose were significantly associated with AHI, p value <0.05.
Conclusions: GDI appears to be a better way to access beta cell function using an oral glucose tolerance test and could be used to identify subjects with poor beta cell function even with normal plasma glucose level in OSAS patients.
