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Pulmonology

Study suggests association of Lung Hyperinflation With Coronary Artery Disease In Smokers

by Vaishali Sharma
written by Vaishali Sharma

In smokers, including those with airflow restriction, a recent study revealed a robust link between lung hyperinflation and clinical and subclinical coronary artery disease (CAD). After accounting for lung hyperinflation, the study revealed no link between FEV1 and emphysema and CAD. The research was published in the Chest Journal.

Hyperinflation is caused by anything that limits the flow of air out of the lungs. The most common culprit is COPD (chronic obstructive pulmonary disease), caused mainly by smoking. Frank C. Sciurba, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, and colleagues addressed the question of which pulmonary phenotypes are associated with coronary artery disease (CAD) in smokers.

The researchers analyzed the data from the University of Pittsburgh COPD Specialized Center for Clinically Oriented Research (SCCOR) cohort (n = 481) and the Genetic Epidemiology of COPD (COPD Gene) cohort (n = 2,580).Participants included current and former smokers with > 10 pack-years of tobacco exposure. Because of methodologic differences, data from the two cohorts were analyzed. Lung hyperinflation was assessed by plethysmography in the SCCOR cohort and by inspiratory and expiratory CT scan lung volumes in the COPD Gene cohort.

Subclinical CAD was assessed as the coronary artery calcium score, whereas clinical CAD was defined as a self-reported history of CAD or myocardial infarction (MI).Analyses were performed in all smokers and then repeated in those with airflow obstruction (FEV1 to FVC ratio, < 0.70).

Key findings include:

  • Pulmonary phenotypes, including airflow limitation, emphysema, lung hyperinflation, diffusion capacity, and radiographic measures of airway remodeling, showed weak to moderate correlations (r < 0.7) with each other.
  • In multivariate models adjusted for pulmonary phenotypes and CAD risk factors, lung hyperinflation was the only phenotype associated with calcium score, history of clinical CAD, or history of MI (per 0.2 higher expiratory and inspiratory CT scan lung volume; coronary calcium: OR, 1.2; clinical CAD: OR, 1.6; and MI in COPD Gene: OR, 1.7).
  • FEV1 and emphysema were associated with increased risk of CAD in models adjusted for CAD risk factors; however, these associations were attenuated on adjusting for lung hyperinflation. Results were the same in those with airflow obstruction and were present in both cohorts.

 

Sciurba and colleagues concluded, “subsequent studies should consider measuring lung hyperinflation and examining its mechanistic role in CAD in current and former smokers.

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Pulmonology

Lung cancer-causing agents must be kept at bay

by Dr. Aditya Kumar Dr. Rakesh Garg
written by Dr. Aditya Kumar Dr. Rakesh Garg

Lung cancer has emerged as one of the commonest cancer these days. We are aware of World Lung Cancer Day which takes place on August 1st every year. This day is symbolic to create awareness not only to early diagnosis and management needs to the lung cancer but more importantly to shoo away the things which can be and are causative of lung cancer. It is the day to talk of healthy lungs and strategies for maintain lung health and not just talk of cancer but to prevent cancer. But the point is that whether really, we do not know that smoking causes lung cancer and health-related issues. We all know! Smoking remains one of the commonest reasons for lung cancers in almost 80% of the patients. All know – SMOKING HARMS! Then why create awareness. If we indulge in activities that harm us despite knowing that it harms, then what to do! We do create awareness during November as well for lung cancer awareness month. Yes, despite all these, there remains the importance of further creating awareness. However, such “day” also needs to create a positive hope among patients suffering from lung cancers. We need to assure all these patients of the support from curative and palliative intent as well.

Lung cancer management strategies have seen many improvements in recent times. Not only the diagnostic modalities have improved but also the treatment strategies including surgery and medical therapy have found a significant improvement in the recent past. Early identification remains the key to appropriate and optimal management. It also becomes prudent to understand that early identification before it spreads remains essential and thus the patient must not ignore symptoms that persist for some time without any explained reason. Timely screening is important, and this awareness must be created in addition to preventive strategies like quit smoking.

At this juncture, it also becomes essential to support the patients, who present in advanced stages of lung cancer. These patients do require medical support and many things can be offered to them for palliative support to improve their quality of life. These patients with advanced cancers have many symptoms like pain, difficulty in breathing, cough, blood in cough,  and so forth. Despite advanced cancers, these symptoms can be optimized to make the patient comfortable. Many strategies are available like the use of medicines (analgesics) and other interventions like removing the fluid from the chest due to cancer and using techniques like pleurodesis which decreases the formation of fluid in the chest and thus makes the patients comfortable by reducing the symptoms due to advanced cancer.

Hoping this World Lung Cancer Day brings a bright ray of happiness by igniting the lamp of creating an aura of positive energy leading to the promulgation of a healthy lifestyle and creating awareness of timely screening and optimal management of lung cancers.

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Experts speakOncology NewsPulmonology

Paradigm shift in the management of lung cancer by robotic surgery

by Dr. Chinnababu Sunkavalli
written by Dr. Chinnababu Sunkavalli

Interestingly Covid crisis has led to more diagnosis of lung cancers thanks to the usage of HRCT for the management of Covid Pandemic. Globally, Lung cancer is one of the commonest cancers and cause of cancer related deaths. It accounts for almost 15 per cent of all new cancer cases and 20 percent of cancer related deaths worldwide. Over 2 million new lung cancer cases are estimated every year in India. Lung cancer constitutes almost eight per cent of all new cancer cases and 10 percent of all cancer related deaths in India.

The worrisome trend is that majority of lung cancers are detected in late stages (70% in third or fourth stage). Smoking is one of the primary reasons for lung cancer. Others are pollution and inherited lung diseases.

The risk factors for development of lung cancer are smoking of tobacco-Both Active and Passive smoking, Pollution, exposure to Radon, asbestos, lung diseases like copd or a family history of lung cancer.

The presenting symptoms of lung cancer are cough which is persistent and doesn’t resolve with routine medication, associated with blood in expectorated sputum or mucus, respiratory symptoms like wheeze, difficulty in breathing, shortness of breath, pain in the thorax and loss of weight.

Robotic surgery or Robotic assisted thoracic surgery is a newer technique in management of lung cancer and other thoracic malignancies. The patients undergoing surgery by robotic approach have smaller incisions and can minimize the risk of lung complications compared to traditional open surgeries which are done by long incisions and spreading the ribs. The vision is magnified, crisp and three dimensional. Though it is called robotic, the surgeon is the commander for this technology and is always controlling the machine by hand and foot movements which in turn is mimicked by the robot. By this paradigm shift in management of lung cancer by robotic technology, the recovery is earlier, pain lesser and hospital stay is shorter.

The use of CT scan annually for early diagnosis of lung cancer has been recommended in high risk patients which is called as screening. However the awareness is limited in our country and it is not being routinely used. If detected early the management of such lung cancers can be curative by surgery and as the disease advances it can be managed by addition of chemotherapy, Immunotherapy and radiation. The surgical stress of patients can be minimized by newer technologies like robotic surgery which has proven to be a boon to patients undergoing surgery for lung cancer.

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Y-shaped tracheal stent
Oncology NewsPulmonology

Doctors treat chemo-resistant carcinoma patient using Y-shaped tracheal stent

by Vaishali Sharma
written by Vaishali Sharma

Doctors recently used a Y-shaped tracheal stent to treat a 51-year-old patient with recurring chemo-resistant carcinoma in his trachea. The patient was only expected to live a few days or weeks, yet stenting extended his life.

The patient’s carcinoma extended to the carina (tracheal bifurcation) and involved the right upper lobe. A team of doctors, led by Dr Vikas Maurya, Director and head of Department, Pulmonology, Fortis Hospital Shalimar Bagh performed the stenting procedure within a span of 30 minutes, extending the life of the patient.

Previously, the same patient had sought treatment in four different hospitals before presenting to Fortis Hospital Shalimar Bagh. On evaluation, it was determined that he has a recurrent chest infection, shortness of breath, and haemoptysis, reported ANI.

Despite undergoing chemotherapy, the tumour continued to grow, and the lumen (air passage) was getting narrower on account of the same, making it difficult for the patient to breathe. This gave rise to further infection, with blood collecting and oozing from the site.

Talking about the treatment, Dr. Maurya said, “The case was complicated as we could not treat the patient with chemotherapy right away as it was a chemo-resistant tumour and had infection as well. Also, the patient and family didn’t want any general anesthesia being given in operation theatre due to advanced nature of the disease.”

Explaining the procedure, he continued, “So, first we controlled the infection and then we put in a Y-shaped trachea-bronchial stent under conscious sedation, in our bronchoscopy suite, thereby covering the tracheal length, carina and upper portion of both right and left main stem bronchi, which covered the growth and after expanding increased the air passage making it smoother.”

“It was a half an hour procedure that was carried out smoothly and through this, we have successfully prolonged the patient’s life, he could have otherwise died in few days to weeks due to airway obstruction caused by increasing tracheal cancer growth. The patient is doing fine now, breathing is comfortable, and has been coming to the hospital regularly for regular check-up and is on targeted therapy by Medical Oncologist,” concluded Maurya.

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world tuberculosis day
Pulmonology

World TB Day 2021: The Challenge of Drug Resistant Tuberculosis

by Vaishali Sharma
written by Vaishali Sharma

Although tuberculosis is considered a disease of the past, there has been a resurgence, especially in developing countries across the world. According to estimates by the World Health Organization, there are over 10 million new cases in the world. It also added that the epidemic is larger than previously estimated, owing to data from India. 60 percent of TB cases are concentrated to six countries. India leads the pack, closely followed by Indonesia and China, while Nigeria, Pakistan are not far behind.

Drug-resistant tuberculosis is particularly hard to treat using medicines that are currently available in the market. Since the drug resistant variants come in different forms – extensively drug resistant and multi drug resistant – patients who are infected are resistant to at least four of the main anti-TB drugs. This is complicated by the fact that rifampicin and isoniazid, two of the most effective anti-TB drugs, have become both ineffective and toxic. So doctors are forced to prescribe less effective drugs that have to be taken over a longer period. For both the variants, patients have to take a lot of pills and daily injections for two years. However, even with this rigorous regimen, the cure rate hover around 60 percent, even at the best centers.

While the standard course of TB medication costs a little over a 1000 rupees, the treatment cost for multi drug resistant TB can go up to 1,50,000 rupees for one year, which is usually the minimum duration of the treatment. The government also does not offer a treatment programme for TB. Although the TB control programme DOTS, which was aimed at providing a standardized drug treatment to TB patients, reached over 600 districts, it was not entirely foolproof. There were considerable delays in diagnosing affected patients and prescribing the right course of medication, not to mention ensuring patients adhered to their regimens, which ended up perpetuating the cycle of transmission. Sticking to a one size fits all approach only amplified the drug resistance.

The harsh reality of the situation is that there have been a high number of TB and drug resistant TB cases in India because of policy shortcomings. Initially, public health officials turned a blind eye to drug resistant patients, and the numbers continued to rise. When the DOTS programme was reassessed and DOTS plus was rolled out, it posed its own unique set of challenges. The drugs that were needed were expensive and often difficult to obtain.

Access to more Promising Drugs

After four decades of dormancy in tuberculosis research, two effective and less toxic medicines were finally released in 2012 – Bedaquiline and Delaminid. Bedaquline blocks the mechanisms used by the TB bacteria to produce energy, effectively killing it in the process. Thousands of patients across the country are in need of these medicines. Although the government announced that patients will get universal access to Bedaquiline, a lot of them are still denied access. According to authorities, its use has to be carefully monitored since it is still in the trial phase. This is complicated by the fact that it is expensive and we are yet to scale up affordability and access.

More recently, a three drug regimen, consisting of Bedaquline, Pretomanid, and Linezolid, showed a 90 percent favorable outcome in treating drug-resistant tuberculosis. The results of the study, which was published in The New England Journal of Medicine, comes as a ray of hope for people suffering from drug-resistant TB. This is no small feat, as Pretomanid is the only other drug developed for TB in over half a century.

It is difficult to tell how soon patients in India will gain access to these drugs. At present, there are only a handful of government hospitals where Bedaquiline is administered, and presenting with a form of drug related TB does not guarantee access. According to government regulations, patients cannot access the drug unless they are residents of the state where it is administered. It is disheartening to see that only a fraction of the people suffering from the disease get the treatment they need. We hope that there is a change in policy that increases access and affordability so that patients get the treatment they need, and TB truly becomes a disease of the past.

Credits: Dr Shuchin Bajaj, Founder Director, Ujala Cygnus Groups of Hospitals

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