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Background: Chronic obstructive pulmonary disease (COPD) is associated with a progressive loss of muscle mass and function and a systemic inflammatory process that can cause sarcopenia. Objective: The objective of this study is to estimate the prevalence rate of sarcopenia in COPD patients and to determine the factors associated with sarcopenic patients living in Western Greece. Methods: European Working Group on Sarcopenia in Older People criteria were applied to 69 outpatients with stable COPD. Body composition, exercise capacity, functional performance, physical activity, and health status were also assessed. COPD disease severity (COPD stage) was evaluated with the Global Initiative for chronic obstructive lung disease. The study protocol was approved by the Ethical Committee of the Technological Educational Institute of Western Greece. Results: The sample comprised 69 patients (59 women and 10 men), with a mean age of 71.33 ± 7.48 years. The prevalence of sarcopenia was 24.6% (n = 17). A high percentage (82.6%; n = 57) of the 69 Greek participants did not perform any regular exercise. The findings of this study demonstrated that sarcopenia was positively associated with COPD, age, body mass index, skeletal muscle mass, hand grip strength, and 4 m test. Conclusions: In conclusion, there is a 24.6% prevalence of sarcopenia in patients with COPD. Further research with larger samples would be indicated to clarify the precise association of specific characteristics of patients with sarcopenia and COPD.

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Context: Nontuberculous mycobacteria (NTM) are ubiquitous mycobacteria present in environment and generally affect patients with either structural lung disease or immunosuppression and commonly involve lungs, lymph node, or skin. Materials and Methods: Between July 2016 and February 2019, 18 cases of NTM were diagnosed and their relevant clinical, diagnostic, and treatment details were recorded after taking informed consent. Results: We report 18 cases of NTM involving lungs (n = 11), skin and soft tissue (n = 3), joint (n = 2), genitourinary (n = 1), and central nervous system (n = 1). History of immunosuppression was present in two patients, whereas history of some form of intervention was seen in six patients. Mycobacterium fortuitum group (n = 5) was the most commonly isolated organism, followed by Mycobacterium avium complex (n = 4), Mycobacterium abscessus (n = 3), Mycobacterium kansasii (n = 2), and Mycobacterium chelonae (n = 1). In two patients, M. chelonae and M. abscessus were isolated in succession. Of these 18 patients, clinical response was present in 15 of the patients. Diagnosis and treatment of NTM in resource limited settings is extremely challenging. Conclusion: Most of the patients with NTM are misdiagnosed and are treated as tuberculosis in India, sometimes with a multidrug resistance regimen, which results in significant morbidity and mortality. We present these cases to shed some light on the epidemiology of NTM in this part of India.

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Background: Whether a Pa_O2: Fi_O2ratio of 150 mmHg could be used to classify patients with acute respiratory distress syndrome (ARDS) as severe or non-severe is unknown. Herein, we study whether Pa_O2: Fi_O2<150 mmHg could be used as a risk stratification and prediction tool for mortality in patients with ARDS. Methods: Patients with ARDS (Pa_O2: Fi_O2ratio ≤300 mmHg) were categorized as nonsevere ARDS (150≤Pa_O2: Fi_O2ratio ≤300 mmHg) and severe ARDS (Pa_O2: Fi_O2ratio <150 mmHg). We compared the physiological characteristics, ventilatory parameters, and mortality between the two groups. Further, we subcategorized those with severe ARDS as very severe (Pa_O2: Fi_O2ratio ≤100 mmHg) or severe ARDS (100O2: Fi_O2ratio <150 mmHg). We also compared the performance of this cut off value with the Berlin criteria using the receiver operating characteristic curve. Results: Four hundred and sixty (256, non-severe ARDS; 204, severe ARDS) patients (mean standard deviation age, 40 (17) years, 55% males) with ARDS were included. Patients with severe ARDS had significantly lower baseline pH and higher Pa_CO2. Patients with severe ARDS also had higher plateau pressure, peak airway pressure, applied positive end-expiratory positive pressure. The odds ratio (95% confidence interval [CI]) of mortality in those with severe ARDS was 1.6 (95% CI, 1.1–2.4). Although the AUC for both the revised and Berlin models was low, on a multivariate logistic regression analysis, after adjusting for age, gender, sequential organ failure assessment score, driving pressure, and mechanical power, Pa_O2: Fi_O2ratio of 150 mmHg remained an independent risk for mortality. Conclusions: The Pa_O2: Fi_O2ratio threshold of 150 mmHg may be used to identify severe ARDS. However, used alone a Pa_O2: Fi_O2threshold of 150 mmHg has poor sensitivity in predicting mortality. Due to the small sample, the results of our study should be confirmed in a larger multicentric study.

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Chronic obstructive pulmonary disease is a prevalent and progressive disease. The recently developed bronchoscopic lung volume reduction (BLVR) techniques offer personalized therapeutic options in subgroups of patients with severe emphysema. Endobronchial and intrabronchial valves (EBV/IBV) achieve lung volume reduction by lobar atelectasis. The lung volume reduction coils (LVRCs) and bronchoscopic thermal vapor ablation (BTVA) induce tissue compression, either mechanically or through inflammatory processes. While the effects of EBV/IBV are reversible by removing the implants, the effects of LVRC are partially reversible and that of BTVA is irreversible. The presence of interlobar collateral ventilation (CV) impacts on EBV/IBV treatment outcome due to its mechanism of action. Therefore, using radiological and endoscopic techniques to assess CV has a vital importance. Current evidence of BLVR demonstrates acceptable safety and short-term clinical efficacy. However, head-to-head trials are lacking, and further research is needed to establish long-term clinical benefit, durability, and cost-effectiveness of these techniques.

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Background: Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE. Materials and Methods: A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019–January 2020). Technical and clinical results, including complications, are reported. Results: Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE. Conclusions: The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

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Introduction: Invasive mucinous adenocarcinoma (IMA) of the lung is a distinct histologic variant of adenocarcinomas comprising about 2%–10% of lung adenocarcinomas. A large proportion of IMAs carry KRAS mutations and only rarely epidermal growth factor receptor (EGFR) mutations or ALK/ROS translocations; thus, most cases are not amenable for targeted therapy at present. This study was conducted to elicit the unique clinicopathological characteristics of IMA. Materials and Methods: Medical records of patients diagnosed with IMA by needle biopsy at Kidwai Cancer Institute, Bangalore, from 2013 to 2018, were retrieved and reviewed. Statistical analysis was performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Results: Four hundred and ninety cases of needle biopsy of the lung were diagonosed at our institute between January 2013 and December 2018. Nine cases (1.8%) were diagnosed as IMA. The median age of presentation was 59 years. Six (66.7%) were current smokers with pack-year > 20. Three (33.3%) of the cases were initially misdiagnosed as pneumonia in view of computed tomography findings. The lung was the most common site of metastasis (77.8%). Serum Carcinoembryonic Antigen (CEA) was elevated in six cases (66.7%). None of the cases had any driver mutations in EGFR gene or ALK and ROS1 translocations. All cases were treated with pemetrexed–carboplatin doublet followed by pemetrexed maintenance till progression. The median progression-free survival (PFS) was 15 months (range: 5–18 months). Docetaxel was given as the second-line chemotherapy in all progressed patients. Best response noted was stable disease, seen in 4 (57.1%) cases. The median PFS for docetaxel was 6 months (range: 3–8 months). The median overall survival was 22 months (range: 9–27 months). Patients with initially raised CEA at progression had a serial rise in serum CEA. Conclusions: IMA is rarely diagnosed on needle biopsies due to insufficient tissue. They mimic pneumonia on imaging, thus delaying diagnosis. EGFR mutations, ALK, and ROS1 translocations are usually negative making them ineligible for tyrosine kinase inhibitors. Response to chemotherapy is modest.

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Introduction: The management of empyema thoracis has evolved over the years. After all lung surgeries chest drain is required, however they suffer from inter observer variability and impair mobility of the patient. However, the newer digital thoracic drain system are portable and have alarms for various situations, furthermore they eliminate inter-observer variability. One such device is Thopaz™ (Medela inc, Switzerland). We wanted to compare efficacy of Thopaz™ with our conventional intercostal chest tube drain in patients undergoing decortications for empyema thoracis. Materials and Methods: One hundred patients were enrolled in study and were randomized into conventional and thopaz group with 50 patients in each group with help of opaque envelopes. Results: Both the groups were comparable in demographic parameters. Majority of the patients in our study were children and young adults. Majority of empyema thoracis involved right side with nontubercular empyema thoracis being the most common cause of decorticartion. Patients managed with Thopaz had a significantly shorter air leak duration, shorter duration of postdecortication chest tube placement and shorter postoperative hospital stay. All postoperative complications were less in Thopaz group. Conclusions: Patients with empyema thoracis undergoing open decortications when managed with digital chest drainage system (Thopaz) experienced faster reduction in air leak, a shorter duration of chest tube placement and in hospital stay. Thopaz usage is also associated with reduction in rate of postoperative complications. We recommend that this digital chest tube drainage system is a very useful tool in armamentarium of thoracic surgeon after lung surgeries.

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Electronic cigarettes use or vaping is popular but has not been proven to be an innocuous substitute for traditional smoking. Several patterns of vaping-associated lung injuries have been reported. We report a case of a 43-year-old female patient, who presented with productive cough and an organizing pneumonia pattern on computed tomography (CT) scan. Recognizing the various CT scan patterns of vaping-associated lung injury is important to make a diagnosis because the cessation of vaping is an important step in the treatment.

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Background: Although histopathological examination of the biopsy specimen is the gold standard for the diagnosis of non small cell lung cancer (NSCLC), a blood-based noninvasive test (liquid biopsy) may prove to be helpful in patients with repeatedly negative biopsy or for response assessment following neoadjuvant therapy. The present study was conducted to explore the diagnostic value of circulating serum microRNA (miRNA) 21 in patients with NSCLC. Methods: This case–control analytical study was carried out in a tertiary care teaching hospital in Northern India. The study consisted of 30 cases of biopsy-proven NSCLC and 30 controls. Serum miRNA-21 expression levels were estimated by extracting total RNA from the serum sample, reverse transcribing it to cDNA and quantified in relation to U6 reference miRNA. Results: A total of 30 patients with NSCLC and 30 controls were included in the study. The subjects were comparable in two groups with reference to age, gender, and smoking. Pathological types were adenocarcinoma in 19 (63.3%) and squamous cell carcinoma in 11 (36.6%) patients. Majority of the patients had advanced disease-AJCC stage III in 15 patients and AJCC Stage IV in 13 patients; two patients had stage II disease. There was a significant upregulation of serum miRNA 21 gene expression in the patients with lung cancer compared to controls (median fold change, 3.39 vs. −2.81, P = 0.00). A fourfold change in serum miRNA 21 is significantly associated with the diagnosis of NSCLC with a high specificity of 97% and area under curve of 0.84 (95% confidence interval of 0.74–0.94). Conclusion: Estimation of serum miRNA 21 expression has potential to be used as liquid biopsy for the diagnosis of NSCLC. Further studies with large sample sizes are warranted to confirm the diagnostic accuracy of serum miRNA 21 expression.

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The role of anesthesiologist in nonoperating room procedures including pulmonary interventions is expanding. Bronchial thermoplasty (BT) is a minimally invasive bronchoscopic intervention for patients with severe asthma refractory to conventional pharmacotherapy. It involves the application of controlled radiofrequency thermal energy to large- and medium-sized airways. We report our experience for perioperative anesthetic management of patients scheduled for BT. Three patients with severe asthma were planned for BT under general anesthesia. After standard monitoring and intravenous cannula insertion, anesthesia was induced with propofol, fentanyl, and rocuronium after preoxygenation and maintained with propofol target-controlled infusion. The ventilation was controlled mechanically with I-gel used for airway management. The oxygen concentration was titrated to 40% or less at the time of thermal activation delivery. The procedure was performed using a thin bronchoscope inserted through the I-gel working port of the catheter mount. The procedures lasted for around 1 h. After completion of the procedure, the residual neuromuscular blockade was reversed, and I-gel was removed. BT requires three separate procedure sessions performed 2–3 weeks apart, and each session sequentially targets right lower lobe, left lower lobe, and bilateral upper lobes. The challenge involved in BT is due to the airway sharing between anesthesiologists and pulmonologists and anesthesia in a nonoperating room setting in patient with uncontrolled severe asthma. A meticulous preoperative evaluation, perioperative anesthetic plan, and periprocedural monitoring can reduce the complications.

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A 58-year-old female with a history of recurrent pneumonia was evaluated for fevers, right lower back pain, and hematuria. A noncontrast abdominal computed tomography (CT) scan showed air and fluid-filled area in the right lower lobe for which a contrast-enhanced CT chest was performed. The CT of the chest revealed the cystic mass was supplied by an anomalous artery from the descending aorta. The patient was then diagnosed with a superinfected bronchopulmonary sequestration which was treated with surgical resection.

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Background: Although lung sarcomatoid carcinomas (LSCa) arised from the epithelial tissue, they have very distinctive features than other non-small cell lung carcinomas in terms of histopathology and survival. It constitutes 0.1%–0.4% of all lung cancers. The aim of our study is to evaluate the survival analysis of LSCa in a single thoracic surgery clinic and to determine the prognostic factors. Materials and Methods: It was a retrospective cohort study. After the approval of the local ethics committee, a total of 34 patients who were operated in our department between January 2010 and December 2018, whose pathologies were reported as sarcomatoid carcinoma was included in the study. The patients were analyzed by age, gender, presence of necrosis in the histopathological examination, tumor stage, tumor diameter, and tumor location. Results: There were 28 males and 6 females. The median age was 60 years (range: 36–80 years). The median survival was 42 months (32.6–52.2 months), and the 5-year overall survival was 33.6%. Significantly negative prognostic factors were tumor diameter and tumor stage (P = 0.003 and 0.001, respectively). Median disease-free interval (DFI) was 38 months (27.3–49.1 months), and 5-year DFI was 32.6%. Conclusion: LSCa are highly heterogeneous epithelial malignancies, and it has worse survival than other epithelial cancers. Relatively, satisfactory results can be obtained in these tumors with surgical treatment.

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Middle lobe torsion is an uncommon complication after right upper lobectomy. Clinical features are non-specific. CECT chest and diagnostic bronchoscopy are the essential investigations for the diagnosis. The treatment of choice is urgent re-exploration with either lobectomy or de-rotation with pneumopexy through thoracotomy or video assisted thoracoscopic approach based on the viability of lobe. Strong clinical suspiscion and early surgical intervention are the key points for success. This report highlights the role of video assisted thoracoscopic approach in the management of this rare complication.

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