Indian Journal of Chest Diseases & Allied Sciences

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To Study the Effect of Interventions to Reduce the Indoor Air Pollution in Asthmatic Children of Rural India
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Kumar, R; Singh, K; Mavi, AK; Nagar, JK; Kumar, M; Mrigpuri, P; Spalgais, S; Ravishankar, N
Background: Around 2.6 billion people cook their food using biomass fuel (BMF), kerosene oil, and coal fuel, by which each year, 4 million people die prematurely from household air pollution or by this inefficient cooking practices. So, this study was planned to measure the effect of interventions of cooking fuel (BMF to LPG) to reduce the indoor air pollution in asthmatic children of rural India. Methods: Prospective observational study was done by door-to-door survey, among school-age children. Households of asthmatic children were encouraged to change their cooking fuel to more secure and were followed up for a period of 9 months. The intervention was in the form of a change of cooking fuel (from BMF to LPG) and proper education. The levels of indoor pollutants (PM10, PM2.5, and PM1) were measured before and after 3 months of follow-up. Result: A total of 56 asthmatic children from 42 households were followed-up for the following 9 months at every 3 months visit. The mean age was 9.27 ± 3.94 years with an equivalent sex ratio. There was at least one smoker in 73.81% of households of asthmatic children. Nearly, 45% of children were living in 101–500 square yard area and 67.86% with the inhabitation of ? 3/room. The level of all particulate matter decreased significantly at 3 months (p < 0.05). At 3, 6, 9 months of follow-up, respiratory symptoms and morbidity significantly diminished. Conclusion: The change in cooking fuel to more secure was found to be one of the factors decreasing indoor pollutants and respiratory symptoms/morbidity among asthmatic children in rural areas.
Screening Parameters for COPD-OSA Overlap Syndrome in COPD Patients: Indian Perspective
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Deshmukh, I; Gothi, D; Vaidya, S; Patro, M.
Introduction: As Indian patients have different predisposing morphological characteristics, we undertook this study to evaluate the clinical profile of overlap syndrome and compare them with COPD patients to find out the screening tools for obstructive sleep apnea (OSA) in Indian chronic obstructive pulmonary disease (COPD) patients. Aims and objectives: • To study the clinical profile of patients with overlap syndrome. • To compare them with COPD patients. • To develop screening tools for overlap syndrome in COPD. Materials and methods: A prospective case-control study was carried out in a tertiary care center. Overnight pulse oximetry was carried out for all COPD patients. Those having snoring or saw-tooth pattern on overnight oximetry were subjected to level 1 polysomnography. About 30 patients of overlap syndrome were compared with 65 COPD patients. Results: The mean age in overlap syndrome group (56.9 ± 6.86 years) was significantly lower (p < 0.01). The daytime PaO2 and lowest nocturnal saturation were significantly lower in overlap group. PaCO2 and forced expiratory volume at 1 second (FEV1) were significantly higher. For diagnosing overlap syndrome, the positive and the negative predictive values of snoring were 84.42 and 100%; of body mass index (BMI) ?25 kg/m2 were 86.67 and 98.88%; and of excessive daytime sleepiness were 37.57 and 97.86%, respectively. Conclusion: Absence of snoring and BMI <25 kg/m2 virtually rules out overlap syndrome. The EDS has a high false-positive rate for predicting OSA. Patients having overlap syndrome have poor daytime and nocturnal oxygenation despite good lung functions.
Relationship between Body Surface Area and Pulmonary Functions in Patients of Silicosis
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Agarwal, S; Singh, M; Sinha, P; Pujani, M.
Background and objective: Silicosis is one of the oldest occupational lung diseases. However, there are very few studies identifying the anthropometric variables associated with silicosis. The present study aimed at studying the association between body surface area (BSA), pulmonary function indices, and 6-minute walk distance (6MWD) in patients with silicosis. Materials and methods: The study was conducted on 102 male patients of silicosis. Height and weight were measured to calculate BSA. Spirometry and 6 minute-walk tests were performed. Data were analyzed using EPI info V 7 software. Student's t-test of significance (ANOVA) was applied to test the difference between means. Results: There are no significant changes found in the 6-minute walk distance with years of exposure and BSA. Statistically significant lower values of pulmonary function indices were observed in patients with BSA <1.6 sq m. Statistically significant higher values of forced expiratory volume in the first second and forced vital capacity were observed in patients with BSA >1.9 sq m in all categories of exposure. Conclusion: In conclusion, patients of silicosis with >1.9 sq m BSA had higher values of pulmonary function indices. Large body size may be of value in protection from developing occupational lung disease.
Carbon Monoxide Poisoning from Heavy Cigarette Smoking Presenting as Delusion in a Patient with a History of Chronic Schizophrenia (Methamphetamine Induced)
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Kaura, V; Kaura, B; Kaura, C.
We describe a case of carbon monoxide poisoning in a 54-year-old male from heavy cigarette smoking presenting as delusions. The patient has a history of methamphetamine-induced schizophrenia now in remission for 2 years, and not on any psychotropics and is drug-free.
Primary Spontaneous Pneumothorax: Surgery for the First Occurrence? An Early Experience from Nepal
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Sapkota, R; Gurung, A; Sharma, A.
Background: Primary spontaneous pneumothorax (PSP) is a common thoracic surgical emergency affecting otherwise healthy young individuals. Its treatment options range from observation to surgery in the form of video-assisted thoracoscopic surgery (VATS). Surgery, generally reserved for recurrence, is gradually being utilized for certain patients presenting with PSP for the first time. In this study, we aim to report our experience of VATS in the surgical management of first episodes of PSP. Methods: A retrospective review of prospectively maintained data on all the patients undergoing surgical management during the first presentation of PSP, over a period of 10 years, was done. Results: Over the period of 10 years, out of 95 patients who underwent thoracoscopic bullectomy for pneumothorax, a total of 42 patients had presented with PSP for the first time. Most (54%) were aged 20–40 years, with male predominance (83%); right-sided (69%); commonest symptom was shortness of breath (83.3%) with a median duration of symptoms of 5.9 days. Apical bullae were the commonest computed tomographic finding (88%). Majority of the patients underwent VATS via three ports, and multiple apical bullae were the most common intraoperative findings. Four patients (9.5%) had an air leak postoperatively, managed conservatively. Average intensive care unit stay was 23 hours; average chest tube duration was 3.6 days; and the average hospital stay was 8.2 days. There was no 30-day mortality and no recurrences were noted during a median follow-up of 2 years. Conclusion: Our initial experience with surgery for the first episode of PSP has been shown to be safe and effective. Larger and more robust studies with longer follow-ups would be necessary to better delineate the role of surgery in such patients.
GOLD Strategy Update 2023: Rationale and Clinical Implications in Indian Perspective
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Bhardwaj, M; Kashyap, S.
Chronic obstructive lung disease (COPD) is a major contributor to global disease burden with a huge socioeconomic impact. Global initiative for chronic obstructive lung disease (GOLD) strategy update 2023 is a step forward in the direction of evidence-based practice. Key topics like taxonomic classification, ABE grouping, single inhaler triple therapy, correct use of inhalers, etc. would have a positive impact on documentation and prescription practices in COPD management. The tobacco consumption habits are peculiar in India. There is a variation in prevalence estimates across diverse cultures. Non-smoking risk factors are important in Indian subcontinent especially in female and younger populations. We discuss the rationale of latest GOLD strategy update, its implications, and challenges in the management of COPD in Indian context.
Psychiatric Morbidity in Patients of Pulmonary Tuberculosis According to Sociodemographic Profile
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Singh, AK; Bajiya, R; Rajender, G.
Background: An association has been described between tuberculosis (TB) and common mental disorders. We aimed to evaluate the patterns of psychiatric morbidities in patients with pulmonary TB. Methods: This was a prospective study conducted over a period of 1 year. A total of 100 patients were recruited for the study. Baseline psychiatric morbidity was assessed after 2 weeks of diagnosis and at the end of an intensive phase (IP). Results: In the present study, 56% of patients with pulmonary TB had morbid baseline psychiatric disorders. The major depressive episode was the most common morbid psychiatric disorder (39%), followed by panic disorder (9%), generalized anxiety disorder (GAD) (6%), and agoraphobia (2%). The psychiatric morbidity dropped to 15%. Major depressive episode dropped to 13%, followed by GAD and panic disorder (1%) each at the end of an IP. Conclusion: Because of high burden of psychiatric morbidity associated with pulmonary TB, there is a need for psychiatric services to be made available to these patients.
Auramine-O Staining vs Ziehl Neelsen Staining: Advantages and Disadvantages
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Sharma, M; Broor, S; Maheshwari, M; Sharma, M; Sudan, DS.
Background: Tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb) is still a major public health concern around the world. Prompt detection of active tuberculosis cases helps in timely therapeutic intervention and reduces community transmission. Despite limited sensitivity, conventional microscopy is still used to diagnose pulmonary tuberculosis in high-burden nations such as India. This study, therefore, was aimed at assessing the diagnostic performance of microscopy by Ziehl Neelsen (ZN) and auramine (AO) staining in the diagnosis of pulmonary tuberculosis. Materials and methods: A prospective comparative study was done on the sputum samples of 2,395 adult patients from November 2018 to May 2020 suspected of having pulmonary tuberculosis visiting the Designated Microscopic Centre of SGT Medical College, Budhera, Gurugram. Each sample was subjected to ZN staining, and AO staining as per NTEP guidelines. Results: Out of the 2,395 samples studied, 161 (6.76%) and 224 (9.35%) were positive by ZN and AO staining methods respectively. Pauci-bacillary cases detected by AO were more than ZN staining. There were 63 more sputum samples detected by AO staining which were missed by ZN microscopy. Conclusion: When compared to conventional ZN staining, the auramine staining technique is more sensitive and takes less time to diagnose pulmonary tuberculosis
Clinico-etiological Characteristics of Cystic Lung Disease: A Retrospective Study
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Singh, P; Vasan, AS; Ahuja, NB; Bhattacharjee, S; Madakshira, MG; Hegde, A.
Introduction: Diffuse cystic lung diseases (CLDs) are a heterogeneous group of uncommon disorders with characteristic imaging appearance. Cystic lung disease is a significant cause of mortality and morbidity with a wide spectrum of radiological presentations and etiological differentials. Though the literature is widely available on radiological approaches to CLD, a knowledge gap exists on the etiological spectrum, especially in the Indian scenario, as it is an orphan group of lung disorders. The interest and experience among pulmonologists regarding CLD are growing with the widespread use of CT scans. Clinical, radiographic, and histological findings are often essential for proper diagnosis, and multidisciplinary approach is required for optimal management of such cases. In our study, through real-world cases, we have highlighted the clinical manifestations and diverse etiological spectrum of CLD. Since these disorders are rare, incurable, and have variable disease progression, the authors have tried to address the holistic approach of this relatively less-understood group of disorders. Aims and objectives: The aim of the study was to identify clinical characteristics and etiological spectrum of patients manifesting with diffuse cystic lung disease radiologically. Materials and methods: In this retrospective analysis, the hospital electronic database was screened with Boolean operations and keywords for cysts OR pneumothorax. Among a total of 4,479 patients admitted to the respiratory ward /ICU during the period of January 2020–September 2022 at a tertiary care center in northern India, 14 patients with radiological diagnosis of CLD matched the relevant search. All relevant data of these patients were retrieved from the records. Results: Our patients presented predominantly with symptoms of cough and breathlessness. About 4 patients had pneumothorax as the first presentation. The mean age of presentation was 42.14 (standard deviation 12.6, age range 16–62 years). About 64% (n = 9/15) patients were females. The various etiologies identified were lymphangioleiomyomatosis (LAM), lymphocytic interstitial pneumonia, Birt–Hogg–Dube syndrome, hypersensitivity pneumonitis, Pneumocystis jirovecii pneumonia, and cystic metastasis, and in one patient, no definite cause was found despite detailed evaluation. Conclusion: Cystic lung disorders are a less commonly diagnosed entity with rare etiologies. In our study, we found a female preponderance and LAM as the commonest CLD. Pneumothorax is a sentinel event and commonly the presenting complaint in CLD. Identification of the etiology can help in institution of definite therapy when available. In view of unpredictable disease progression and outcome, these diseases warrant follow-up and imaging surveillance.
Pulmonary Hydatid without Liver Involvement: A Case Series
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2023-03) Prakash, AK; Jain, R; Datta, B; Jain, SK; Rane, N; Thombare, B; Khan, AZ; Jaiswal, A.
Pulmonary hydatid is not a rare disease. But raising a suspicion for its diagnosis is limited. There are limited approaches for the diagnosis and treatment of the same. We present here four cases of pulmonary hydatid, without liver involvement, with emphasis on how it was misdiagnosed and received multiple treatment and landed into complications. Most of our cases presented with cough, sputum and hemoptysis. For these nonspecific signs and symptoms, patient is generally treated on a different line of diagnosis. Two of the cases were already treated for abscess and fungal infection. One of the patients was on antitubercular treatment. One of our cases was secondarily infected with aspergilloma. One of the cases was referred to oncologist to start chemotherapy. Interestingly, to raise a suspicion, none of our cases had liver involvement. A detailed history revealed expectoration of white salty material in sputum, living with sheep and dog and expectorating grape-like vesicles in sputum. History helped us to put hydatid as one of our differentials. Echinococcal serology was positive in three cases. Only three cases had on-table appearance of hydatid cyst. All four cases underwent surgical management for complete cure. There is need for strong suspicion and a detailed history and proper set of investigations help in timely diagnosis and management of pulmonary hydatid disease.
Kytococcus schroeteri: An Emerging Pathogen on the Horizon
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-03) Ketan, P; Sivaradjy, M; Abhinand, S; Lulu, J; Surendran, D; Sastry, A S.
Kytococcus has long been considered to be a skin commensal or environmental contaminant. However, it has emerged as an aetiological agent of prosthetic valve infective endocarditis, pneumonia, bacteremia, osteoarticular, and implant/device infections, especially in patients with immunocompromised conditions, such as haematological malignancies, febrile neutropaenia and in patients on immunosuppressant therapy. We report a case of prosthetic valve endocarditis associated with Kytococcus schroeteri in a patient with rheumatic heart disease and mitral valve replacement. Special efforts to reach correct identification have to be made as Kytococcusis, commonly resistant to penicillins and oxacillins; and often needs prolonged treatment with glycopeptides containing combination antimicrobial therapy.
揂ir Bubble Sign� and Fibreoptic Bronchoscopy in Complicated Pulmonary Hydatid Cysts: Steps in the Right Direction
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-12) Chatterjee, A; Sarma, MK; Mitra, S.
Intact pulmonary hydatid cysts are often discovered incidentally on chest X-rays (CXRs) as rounded opaque lesions with smooth borders. Cyst rupture and infection (complicated hydatid cyst) often change the radiologic appearance delaying diagnosis. Air bubble sign on computed tomography is recognized as a sign of high sensitivity and specificity in the diagnosis of complicated hydatid cysts when compared to other classical radiologic signs. Bronchoscopy is not a preferred investigation in patients with intact hydatid cysts but may have a major role in patients with complicated hydatid cysts with atypical presentation. In the present case series, we attempt to highlight the importance of the 揳ir bubble sign� and the identification of a whitish membrane at bronchoscopy in the diagnosis of complicated hydatid cysts.
Aeroallergen Sensitivity in Subjects with Nasobronchial Allergy: Contemporary Trends in Kerala
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-03) Rajesh, V; Dhanya, E; Divya, R; Augstine, J.
Syndrome Z: Its Response to CPAP Therapy
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-06) Babu, A; Pandey, A; Baburao, A; Narayanswamy, H.
Background: Metabolic syndrome is a constellation of cardiovascular risk factors and its prevalence in obstructive sleep apnea (OSA) is high. The association of OSA and metabolic syndrome is termed as syndrome Z. The effect of continuous positive airway pressure (CPAP) on metabolic syndrome is still controversial. Materials and methods: A total of 145 newly diagnosed patients with OSA were enrolled in this prospective interventional study, who underwent CPAP therapy for 8 weeks. Baseline data including anthropometric variables, blood pressure, fasting glucose levels, insulin resistance and fasting lipid profile of all the study patients were collected before and after the intervention. We determined prevalence of metabolic syndrome in OSA and the effect of CPAP on the components of metabolic syndrome was determined. Results: One hundred-and-six (73.1%) patients were found to have metabolic syndrome. Eighty-four patients were compliant with CPAP therapy. There was statistically significant reduction in glucose systolic (5.5 mm Hg, p = 0.001) and diastolic blood pressure (3.5 mm Hg, p = 0.002), fasting (4.2 mg/dL, p = 0.02), homeostasis model assessment insulin resistance (1.4, p = 0.04) and triglycerides (17.3 mg/dL, p = 0.008) after CPAP therapy. There was modest reversal of metabolic syndrome manifestations in 22 of 84 patients (26.2%) after CPAP therapy. In the CPAP complaint group, a significant reduction in dyslipidemia (p = 0.04) was noted compared to non-compliant group. Conclusion: In patients with syndrome Z, 8 weeks of CPAP therapy was associated with reduction in both systolic and diastolic blood pressure, insulin resistance and triglycerides and modest reversal of metabolic syndrome manifestations.
Two Unusual Presentations of Gestational Trophoblastic Neoplasia: Cutaneous Metastasis and a Large Solitary Lung Lesion
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-12) Mitra, S; Das, AK; Majumdar, A; Mondal, D
Gestational trophoblastic tumors, an uncommon group of pregnancy-related neoplasms, should be considered in any premenopausal patient presenting with metastatic disease from an unknown primary. A raised hCG and exclusion of pregnancy are often the only requirement in this situation. Although a potentially curable condition, a late diagnosis and the extent of the metastatic disease often determine the prognosis. Here we describe two young women with metastatic GTN, the first presenting with a very unusual finger metastasis and the second with a rare large solitary lung lesion with brain metastasis.
Combined Allergic Bronchopulmonary Aspergillosis and Tropical Pulmonary Eosinophilia: A Rare Co-occurrence
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-12) Sodhi, MK; Aggarwal, D; Dutta, K
Allergic bronchopulmonary aspergillosis (ABPA) and tropical pulmonary eosinophilia (TPE) are common lung diseases presenting with peripheral blood eosinophilia. Although these have been widely reported both from India and outside, simultaneous co-occurrence of the two diseases has not been reported so far. We hereby present a case of an elderly male, a known case of asthma, who was diagnosed to have concurrent ABPA and TPE. Partial clinical response as well as the persistence of eosinophilia after ABPA treatment raised the suspicion that subsequently led to the diagnosis of TPE. The concurrent treatment of both conditions led to satisfactory clinical and serological improvement.
Clinical Profile, Adverse Drug Reaction, and Outcome of Category V Patients at a Drug-resistant Tuberculosis Center, Mumbai
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-06) Thakare, P; Utpat, K; Desai, U; Joshi, JM.
Background: Drug regimens for the treatment of drug-resistant tuberculosis (DR-TB) are composed of salvage drugs to which a patient has never been exposed to previously. Methods: A retrospective observational study was conducted in a DR-TB Center attached to a medical college in a metropolitan city using the database of category V patients (n = 100) who were prediagnosed and referred. The clinical records of the patients were reviewed for demographic data, history, sputum examinations, co-morbidities, and adverse drug reactions (ADRs). The therapy outcomes were assessed as per Revised National Tuberculosis Control Programme (RNTCP) guidelines. Results: Their mean age was 29.1 years; there were 57 males. Mean body weight was 41.8 kg. Pediatric patients (age 12�) constituted 13%. All the patients had pulmonary TB. Of the 100 cases, 80 were Category IV failure; 5% were defaulters of Category IV; and 15% were treated with second-line drugs adequately in private. Durg-susceptibility test (DST) showed extensively drug-resistant TB (XDR-TB) in 63 and pre-XDR-TB in 37 patients. The outcomes of Category V treatment were cure (7%), died (33%), failed on therapy (4%), transferred out (16%), lost to follow-up (2%), and still on the therapy (35%). Various comorbidities were present in 25% patients. ADRs were seen in 44%, and peripheral neuropathy (18%) was the most commonly observed ADR. Conclusions: DR-TB patients were younger and males were more affected. Mortality of Category V regimen was high (33%). Most common comorbidities were anemia and hypothyroidism. Adverse reactions were common (44%); ADR peripheral neuropathy being the most common.
Malignant Pleural Effusion: A Continued Relevance of Closed Needle Pleural Biopsy
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-12) Gupta, A; Desai, U; Joshi, JM.
Introduction: Thoracocentesis and pleural biopsy are recommended for the evaluation of undiagnosed exudative pleural effusion. There are multiple etiologies associated with them, out of which malignancy is one of them. Hence, the diagnosis of malignant pleural effusion (MPE) has been proposed in recent perspectives. We aimed to find the profile of MPE, efficacy of percutaneous closed needle pleural biopsy (PCNPB) in diagnosing MPE, overall yield, and complication rate to evaluate the continued relevance of this traditional procedure. Methods: This was a prospective study carried out on consecutive consenting patients at the Department of Pulmonary Medicine at a tertiary care hospital from July 2016 to May 2018. The diagnosis was based on cytobiochemical, microbiological, and histopathological results along with clinical history. Data were analyzed with respect to pleural fluid assessment in terms of cytobiochemical and microbiological evaluation; while pleural biopsy was studied histopathologically. Results: Two hundred and fifty patients with exudative pleural effusion were enrolled. Tuberculosis (218, 87.2%) was the most common etiology followed by malignancy (22, 8.8%). The most common presenting complaint was chest pain (100%) followed by dyspnea (90.47%). Metastatic adenocarcinoma was found in 81.81% followed by mesothelioma in 18.18%. The sensitivity of pleural biopsy for malignancy was found to be 63.63% (p < 0.003, odds ratio [OR]: 2.01), and those fulfilling Leung's criteria, sensitivity was found to be 90.90% (p < 0.001, OR: 3.67). The sensitivity of pleural fluid for malignancy was 18.18% (p < 0.05, OR: 1.51). All cases of mesothelioma have asbestos exposure. The complication in the form of mild post-pleural biopsy pain was encountered in 10%, which required mild analgesics. Other complications in the form of self-resolving pneumothorax were seen in 6%, which increased hospital stay to 2�days and self-resolving hematoma (3%). Conclusion: In this modern era, PCNPB still holds high sensitivity, efficacy rate, and relevance for diagnosing MPE with less complication rate, less hospital stay, and can be done on a daycare basis. Also, we have very less research and paperwork regarding this topic.
Isolated Index Finger Dactylitis with Hilar Adenopathy
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-03) Sah, RB; Aswith, J; Ojha, U; Vaidya, S; Patro, M.
Dactylitis due to tuberculosis (TB) is an extremely uncommon manifestation of TB. We report a unique case of isolated index finger dactylitis with right hilar adenopathy due to TB in a 15-year-old immunocompetent student. High index of clinical suspicion, radiological findings and histological confirmation helped in the diagnosis. Anti-tuberculous therapy remains the cornerstone for the management of these cases.
Endobronchial Ultrasound Bronchoscopy in Patients with Acute Respiratory Failure on Noninvasive Ventilation: Report of Two Cases
(Jaypee Brothers Medical Publishers Pvt. Ltd, 2022-12) Jha, OK; Yadav, S; Sircar, M; Gupta, N
Fiberoptic bronchoscopy (FOB) has simplified the direct examination of the lungs and is widely used for diagnosis and therapy. Fiberoptic bronchoscopes occupy a significant proportion of cross-section area of central airways, which can affect lung mechanics and gas exchanges that may lead to desaturation and cardiac arrhythmia. This makes bronchoscopy in critically ill patients with respiratory failure even more challenging. Use of noninvasive mechanical ventilation (NIV) may help to avoid use of invasive mechanical ventilation in selected patients with acute respiratory failure. It has been shown to be useful in hypoxemic patients to facilitate bronchoscopic examination for bronchoalveolar lavage, bronchial brushing, endobronchial biopsy (EBB), and transbronchial lung biopsy (TBLB). Noninvasive mechanical ventilation has also been used to facilitate other endoscopic procedures including transesophageal echocardiography (TEE) and upper gastrointestinal endoscopy for diagnostic and therapeutic interventions in hypoxemic patients. Endobronchial ultrasound (EBUS) bronchoscope, having a wider diameter than a conventional bronchoscope, may have a more pronounced effect on lung mechanics and gas exchanges, and its use in patients on NIV has not been reported. Contraindications of EBUS are mostly relative and similar to FOB. There are several studies suggesting the safety of NIV-supported FOB in hypoxemic patients. We describe our experience of the first two EBUS bronchoscopies and transbronchial needle aspiration (TBNA) was done in hypoxemic patients with NIV support.

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