FeNO may help to diagnose cough variant asthma,DR.D.K.JHA,M.D.

CHILD AND CHEST HEALTH CARE > 2019

Year: 2019

FeNO may help to diagnose cough variant asthma,DR.D.K.JHA,M.D.

DR DEV KUMAR JHA - 12 Nov, 2019 - Respiratory, - 0 Comment

Asthma,only as cough

Asthma is a leading cause of respiratory morbidity all over the world whether it be adult or children.In cough variant asthma,patients have only symptom of troublesome cough for a long period.They do not complaint of tightness of chest,difficulty in breathing,or wheezing any time in the course of their illness.On CHEST auscultation,there is no adeventitious sound in the form of wheeze.This type of cough presents a difficulty in front of treating physician for the accurate diagnosis.It may be asthma or other diagnosis which needs meticulous investigations.It is also difficult to convince to patients or parents that it may be asthma,because there is a common belief among patients and parents that asthma means difficulty in breathing.On the other hand,spirometry,which is a goldstandard diagnostic test for asthma, done on such type of asthma patients are usually normal.

FeNO(Fractional excretion of nitric oxide) is measured by a portable machine,which is hand held and subject is asked to exhale through the mouth piece connected to a hand held device.The measurement is in part per billion(ppb).The normal and abnormal levels have been validated in adults,not in children.But its level when it is high,well correlates with eosinophilic inflammation of airways in children and it can be performed easily in school going children.

In a study ,32 patients with an average age of 42.5 years were included.All had only cough for a long period(chronic cough),normal blood eosinophil count,normal chest X-Ray,normal spirometry results but abnormal ACT(Asthma control test) and positive skin prick test for environmental antigens.9 healthy persons were included for control with the mean age of 47 years.FeNO measurements were taken with the help of FeNO analyser.

FeNO were significantly elevated with the mean value of 64.4ppb in 91%(n29) of patients.The normal cut off value for adults is 25ppb.In healthy controls,the mean value measured was 16ppb.

REFERENCES:Nsouli T, Diliberto N, Nsouli S, Zamora S, Nsouli A, Bellanti J. Lack of concordance between FeNO and spirometry in patients with chronic cough. Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX. Abstract A202

SPUTUM EOSINOPHIL COUNT CORRELATES WITH BLOOD EOSINIPHIL COUNT AND CAN DIFFERENTIATE ASTHMA AND COPD,DR.D.K.JHA.M.D.,

DR DEV KUMAR JHA - 02 Nov, 2019 - Respiratory, - 0 Comment

Sometimes ,it becomes difficult to differentiate asthma,COPD and asthma-COPD overlap

It is easy to take sputum sample in adult, but in children it is difficult

So,any sample can be used depending upon the age of patient,if both correlates well

Researchers from Japan retrospectively,evaluated 195 patients with Asthma(n95),COPD(n61) and asthma COPD overlap(n39) between 2015 to 2017

Sputum sample was centrifuged at 500g for 5 minutes,then transferred to a glass slide.It was then crushed with a rotatory motion with another glass slide.Cell counts were done after proper staining.

To assess whether the sputum eosinophil counts-/>3% correlates with blood eosinophil count,researchers constructed ROC(Receivers operative curve)

Patients with Asthma and asthma COPD overlap had significantly higher eosinophil count and lower neutrophil counts during stable period as compared to patients with COPD . But it was not so during exacerbations.

MEAN eosinophil and neutrophil counts: asthma, 17.4% and 78.8%, respectively; COPD, 1.8% and 95.6%, respectively; and asthma-COPD overlap, 11.8% and 84.2%, respectively).It was during stable period

But,during the periods of exacerbation, following was the results

MEAN eosinophil and neutrophil counts: asthma, 15.0% and 83.3%, respectively; COPD, 4.8% and 86.4%, respectively; and asthma-COPD overlap 17.7% and 79.9% respectively.

There was significant correlations between blood and sputum eosinophil percentage among all categories of patients both during stable and during the period of exacerbations

It was clear from the analysis of ROC curve, that the blood eosinophil can predict sputum eosinophil count3% during stable period as well as during the period of exacerbations.Following is the results.

During stable period  (AUC, 0.75 [95% CI, 0.66-0.84]; cutoff, 235 µL; sensitivity, 75.4% and specificity, 71.3%) and during the exacerbation period (AUC, 0.80 [95% CI, 0.66-0.94]; cutoff, 351 µL; sensitivity, 61.1% and specificity, 97.1%).

So  we can take either sample according to feasibility and during the stable period ,we can diffferentiate between asthma,COPD and asthma COPD overlap

REFERENCES:

 

Tamura K, Shirai T, Hirai K, et al. Differentiation of asthma, COPD, and asthma-COPD overlap via a simplified sputum cell count method. Presented at: CHEST Annual Meeting 2019; October 19-23, 2019; New Orleans, LA. Abstract 464.

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Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 29 Aug, 2019 - Uncategorized, - 0 Comment

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UPDATED RECOMMENDATIONS IN PEDIATRIC TUBERCULOSIS,2019, DR. D. K. JHA, M. D

DR DEV KUMAR JHA - 05 Apr, 2019 - INFECTIOUS DISEASES,Respiratory, - 0 Comment

Pediatric tuberculosis is a burden to society and nation .

It is prevalent in every society and every nation.

It spreads by aerosols which comes in air after coughing by a diseased person and then inhaled by healthy person .

In children ,it is mostly contracted by a diseased adult suffering from pulmonary tuberculosis .

Lifetime risk for an infected child to become diseased is 10%.

CBNAAT-cartridge based nucleic acid amplification test, also known as GeneXpert test is now investigation of choice to detect Mycobacterium tuberculosis in children suspected to be suffering from tuberculosis .

The sensitivity of this test in sputum smear positive case is 98% and specificity is 99% but in smear negative and culture positive  cases its sensitivity is only 72% but specificity is 99%

In GA(gastric aspirate sample ) the sensitivity is only 68% in culture positive sample  and specificity is 99%.

Presently it is done on sputum, gastric aspirate ,CSF ,pleural fluid ,lymph done aspirate ,ascitic fluid,synovial fluid but  not on blood .

In lymph node aspirate,the positivity is 35%.

In some children,in which induced sputum and gastric aspirate are negative ,BALf,bronchoalveolar lavage fluid obtained by bronchoscopy has been found to be positive.

The sensitivity is  low in  Synovial fluid,pericardial fluid,ascitic fluid and very low in pleural fluid.

SO ,NEGATIVE TEST RESULT OF CBNAAT/GeneXpert TEST DOES NOT RULE OUT TUBERCULOSIS

Only one sample is needed and if unable to send the sample to lab immediately, it can be stored safely in refrigerator for 7 days but should not be freezed .

It is a real time PCR test and gives result in 2 hours.

It detects Mycobacterium tuberculosis as well as its resistance to Rifampicin.

If resistance to Rifampicin is detected and there is no suspicion of resistant tuberculosis clinically,then a fresh second sample is sent.

In second sample, if there is sensitivity to Rifampicin, it is labelled as Drug sensitive TB.

In GeneXpert Ultra test,second sample is not required.

The yeild is high in this test if there is chest X-ray findings suggestive of tuberculosis.

In case of only clinical suspicion with no radiological findings,the sensitivity is approximately 10%

SO,FOR THE HIGH YIELD,THIS TEST SHOULD BE SENT WHEN THERE IS SUSPICIOUS LESION ON CHEST X-RAY

In case of pleural effusion,the highest yield is from the examination of pleural biopsy which is positive in 80% cases.

The culture of pleural fluid is positive in only 10% of cases.

Other recommended tests are LPA-Line probe assay and LAMP-Loop mediated isothermal amplification.

These tests (CBNAAT,LPA annd LAMP)are called WRDT-WHO recommended rapid detection test.

The Gold standard diagnostic test is now, liquid culture in the form of MGIT-Mycobacterium growth indicator tube culture which gives result in 3 weeks.Previously it was solid culture.

Culture is positive in 1/3 to 1/2 cases of Tuberculosis.

FUTURE PROSPECT: CBNAAT has been used to detect Mycobacterium tuberculosis in stool sample  in children.Its sensitivity in one study in children and persons with HIV has been found to be over 80% and specificity over 95% when compared to respiratory sample.

After multicentre study,it may become the preferred sample for children in which respiratory sample is difficult to obtain.

TREATMENT:

Category II (CAT II) Treatment comprising of 2HRZES+1HRZE+5HRE has been completely withdrawn now.

There is  only one category now, for all patiens ,comprising of 2HRZE+4HRE,FIRST LINE ATT

For newly diagnosed cases,whether smear positive or smear negative this treatment should be completed for 6 months.

All patients,who have not taken ATT previously or have taken it for less than 4 weeks are labelled as New Case

In cases of neurotuberculosis or spinal tuberculosis,the continuation phase comprising of HRE should be extended for 8 months.

In cases of relapse,defaulters, retreatment,treatment after failure, and any contact with resistance tuberculosis,the sample should be sent for DST-Drug sensitivity test,  while the treatment started as 2HRZE+4HRE.

If the result comes as sensitive to first line medications,the treatment should be completed with this regimen only

If resistance comes to any drug, then the second line drugs should be started according to the sensitivity pattern.

Second line drugs are less potent and should be given for prolonged time.

Two highly potent drugs Dalaminid and Bedaquilline are now recommended for treatment of children with resistant tuberculosis.

Bedaquilline is recommended for children 6 years and above.

Dalaminid is recommended for children 3 years and above.

These two drugs are available at selected centres in India

In cases of LTBI -Latent tuberculosis bacillus infections,in which only Tuberculin sensitivity test or IGRA is positive but there is no clinical symptom and sign or any lesion in any organ suggestive of tuberculosis,no treatment is given in India.

In Western countries,the current recommendation is to treat LTBI with 12 Doses of HP-3HP-(3 months of HP)

Previously it was recommended for adults,but now it is recommended in children also

In such cases(LTBI),weekly doses of Rifapentine and isoniazid is given for 12 weeks.

Currently,it is not recommended for children below 2 years of age.

All children receiving isoniazid should be given daily dose of 10 mg of pyridoxine.

Definite indications of steroid along with ATT are TBM,Pericarditis,Addisons disease,Miliary TB with alveolocapillary block and TB uveitis.

Steroid can be given in endobronchial tuberculosis,pleurisy with severe distress,bronchial compression,mediatinal compression syndrome,laryngeal TB,and TB-IRIS(Immune reconstitution inflammatory sundrome).

Evidence is not sufficient for tuberculoma.

Prednisolone 1-2 mg/kg/day or dexamethasone 0.6mg/kg/day or any steroid in equivalent doses ,should be given for 4 weeks then tapered over next 4 weeks.

REFERENCES:

RNTCP Updated Pediatric TB Guidelines 2019 developed by Revised National TuberculosisControl Programme and Indian Academy of Pediatrics.

Guidance document draft as on 04.02.2019,Central TB division,Ministry of Health and Family Welfare,New Delhi India

CDC:Treatment Regimen for Latent TB infection

CDC:The 12 dose Regimen forLatent Tb infecvtion Treatment:Fact Sheet for clinicians

Eur Respir J 2019 53:1801832; published ahead of print 2018,
doi:10.1183/13993003.01832-2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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STEROID RESISTANT ASTHMA CAN BE PREDICTED NOW,DR.D.K.JHA,MD

DR DEV KUMAR JHA - 24 Mar, 2019 - Respiratory, - 0 Comment

Asthma is the most common chronic disorder in children all over the world.

Its incidence and prevalence has increased in last decades even in the presence of more advance diagnostic modalities and more sophisticated treatments available now a days.

The cornerstone of controller medication for asthma is inhalational steroid.

Injectable and or oral steroid  is the principal agent for the treatment,and becomes life saving, when a child lends up in emergency department with acute severe exacerbation of asthma.

Few children with asthma do not respond to steroid therapy and the physicians lend up in problem when they give steroid, spend time and then do not see any improvement in the child.

In such situations,if we know which child will not respond to steroids,will be very helpful.

In a research study,192 asthmatic children who were on inhalation steroid treatment and 130 healthy were included.

Serum level of OX40L was estimated in all children.Its level was correlated with clinical characteristics of asthma and the response of steroid treatment.Serum levels of eosinophils,Nutrophils,IgE,Interleukin 6 and TSLP(Thymic stromal lymphopoietin) were estimated in all children.

There was a positive correlation between serum levels OX40L and serum levels of Eosinophils,Nutrophils,IgE,Interleukin 6 and TSLP which are known serum markers of asthma and its severity.

There was a significant high level of  serum OX40L  in asthmatic children in comparision to healthy children and the level of serum 0X40L was much higher in steroid resistant asthma(SRA) in comparision to Steroid sensitive asthma(SSA)

There was a negative correlation between serum level of 0X40L and Asthma score test(AST) and FEV1 which are measured to assess the severity of asthma at regular intervals.

So,the high level of serum 0X40L has 2 meanings,firstly, it indicates more severe asthma and secondly very high level may suggest the asthma is unresponsive to steroid treatment.

In future , the agent targetting this 0XL40 is required to customise the treatment of asthma.

 

REFERENCES:Elevated serum OX40L is a biomarker for identifying corticosteroid resistance in pediatric asthmatic patients
BMC Pulmonary Medicine — Ma SL, et al. | March 21, 2019

 

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