Background

Indigenous children in high-income countries have a heavy burden of bronchiectasis unrelated to cystic fibrosis. We aimed to establish whether long-term azithromycin reduced pulmonary exacerbations in Indigenous children with non-cystic-fibrosis bronchiectasis or chronic suppurative lung disease.

Methods

Between Nov 12, 2008, and Dec 23, 2010, we enrolled Indigenous Australian, Maori, and Pacific Island children aged 1—8 years with either bronchiectasis or chronic suppurative lung disease into a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial. Eligible children had had at least one pulmonary exacerbation in the previous 12 months. Children were randomised (1:1 ratio, by computer-generated sequence with permuted block design, stratified by study site and exacerbation frequency [1—2 vs ≥3 episodes in the preceding 12 months]) to receive either azithromycin (30 mg/kg) or placebo once a week for up to 24 months. Allocation concealment was achieved by double-sealed, opaque envelopes; participants, caregivers, and study personnel were masked to assignment until after data analysis. The primary outcome was exacerbation (respiratory episodes treated with antibiotics) rate. Analysis of the primary endpoint was by intention to treat. At enrolment and at their final clinic visits, children had deep nasal swabs collected, which we analysed for antibiotic-resistant bacteria. This study is registered with the Australian New Zealand Clinical Trials Registry; ACTRN12610000383066.

Findings

45 children were assigned to azithromycin and 44 to placebo. The study was stopped early for feasibility reasons on Dec 31, 2011, thus children received the intervention for 12—24 months. The mean treatment duration was 20·7 months (SD 5·7), with a total of 902 child-months in the azithromycin group and 875 child-months in the placebo group. Compared with the placebo group, children receiving azithromycin had significantly lower exacerbation rates (incidence rate ratio 0·50; 95% CI 0·35—0·71; p<0·0001). However, children in the azithromycin group developed significantly higher carriage of azithromycin-resistant bacteria (19 of 41, 46%) than those receiving placebo (four of 37, 11%; p=0·002). The most common adverse events were non-pulmonary infections (71 of 112 events in the azithromycin group vs 132 of 209 events in the placebo group) and bronchiectasis-related events (episodes or investigations; 22 of 112 events in the azithromycin group vs 48 of 209 events in the placebo group); however, study drugs were well tolerated with no serious adverse events being attributed to the intervention.

Interpretation

Once-weekly azithromycin for up to 24 months decreased pulmonary exacerbations in Indigenous children with non-cystic-fibrosis bronchiectasis or chronic suppurative lung disease. However, this strategy was also accompanied by increased carriage of azithromycin-resistant bacteria, the clinical consequences of which are uncertain, and will need careful monitoring and further study.

Long-term azithromycin for Indigenous children with non-cystic-fibrosis bronchiectasis or chronic suppurative lung disease (Bronchiectasis Intervention Study) : a multicentre, double-blind, randomised controlled trial

To the Editor, The current documented global prevalence of asthma is over 300 million and is continuously rising due to rapid changes in gene‐ environment interactions. Documentation of expiratory airflow obstruction at diagnosis and resolution in follow‐up is necessary for its appropriate management. Pulmonary function monitoring is also desired in restrictive lung diseases, including COVID‐19 pneumonia, at the start and during subsequent visits. Spirometry, the widely used technique for measuring lung functions, has been questioned in recent times due to the potential risk of outspreading COVID‐19 apart from its restricted diagnostic utility for smaller airways and restrictive lung diseases. Another important drawback is a requirement of a patient's understanding and optimal performance during the procedure which makes this procedure a nightmare for the pediatric population. With the pandemic progressing at the current pace, we are far away from the trivialization of the situation. With the limited utility of aerosol‐generating and strenuous procedures like spirometry, there is an immediate need for safer alternatives to monitor lung functions in the indigent. Procedures involving vigorous expiratory efforts like coughing, sneezing, and spirometry can impose an enhanced transmission risk of respiratory infections among the healthcare workers and fellow pulmonology patients, due to increased aerosol generation. Several studies have reported that forceful deep exhalation increases the particle concentrations as well as the duration of suspension in the surrounding environment (Table 1). The phenomenon of increased aerosol generation during forceful breathing maneuvers can be explained by the “airway reopening hypothesis.” During physiological conditions, the apical portion of the lungs is more ventilated than basal segments, the condition is further aggravated and mismatched during disease. A tidal breath, at low volume, will not disturb the dependent airways configuration whereas a forceful breathing effort will reopen the collapsed segments causing more turbulence and hence increased production of aerosols. Any procedure involving forceful inspiration and/or expiration is highly likely to cause more airflow disruption and further aerosol generation. As the procedure of spirometry requires cooperation and forceful respiratory efforts, it is cumbersome in children, the elderly, patients with neuromuscular weakness, and in those with learning difficulties. Moreover, its use has been restricted to a minimum during the current pandemic situation. Using negative pressure rooms, HEPA filters, adequate ventilation, hand hygiene, complete personal protective equipment, and social distancing will only reduce the spread and contamination but will not eliminate the aerosol generation. The current COVID‐19 pandemic has reemphasized the unmet need of more child‐friendly breathing operations with lesser aerosol production for monitoring pulmonary functions.

Oscillometry-A reasonable option to monitor lung functions in the era of COVID-19 pandemic.

Incense burning is practiced alongside many sacred rituals across different regions of the world. Invariable constituents of incense brands are 21% (by weight) herbal and wood powder, 33% bamboo stick, 35% fragrance material, and 11% adhesive powder. Major incense-combustion outputs include particulate matter (PM), volatile organic content, and polyaromatic hydrocarbons. The relative toxicity of these products is an implicit function of particle size and incomplete combustion, which in turn vary for a specific incense brand. Lately, the attention given to the Air Quality Index by international regulatory bodies has created concern about mounting PM toxicity. The uncharacteristically small physical dimensions of these entities complicates their detection, and with no effect of gravity PM fractions rapidly contribute to oxidative stress, enhancing random biochemical reactions upon being inhaled. Incense burning generates four times the PM extent (45 mg•g-1) of cigarettes (~10 mg•g-1). Several poisonous gases, such as CO, CO2, NO2, and SO2, and the unavoidable challenge of disposing of the burnt incense ash further add to the toxicity. Taken together, these issues demonstrate that incense burning warrants prompt attention. The aim of this article is to highlight the toxicity of incense-combustion materials on the environment and human health. This discussion could be significant in framing future policy regarding ecofriendly incense manufacture and reduced usage. 

/pdf/health-and-environmental-risks-of-incense-smoke-mechanistic-1rgsiv06.pdf

Health and Environmental Risks of Incense Smoke: Mechanistic Insights and Cumulative Evidence

The prevalence of asthma is increasing rapidly, worldwide, due to changing gene-environment interactions. The rate of rise is more in resource poor nations due to lack of knowledge and non-availability of expertise. Monitoring of lung functions is mandatory for diagnosis and further management of asthmatic patients. Spirometry, the widely available investigation, is the gold standard test used for mapping pulmonary dynamicity. It has got its own limitations in the form of operational difficulties in children, the elderly, and in those with neuromuscular or behavioral issues. In the current era of COVID-19 pandemic, the utility of spirometry has been further restricted to selected cohort only, due to potential risk of viral transmission during the procedure. Oscillometry technique has been used previously, to monitor lung functions, with promising results. Ultrasonic waves of various frequencies accompany the tidal breath of patients and respiratory impedance is calculated by measured pressure and flow signals from exhaled breath. The results are interpreted in the form of resistance, reactance, resonant frequency, and reactance area. Various manufacturers have developed different mechanical models with slight variation in impulse pattern till date. There are certain distinct advantages of oscillometry over spirometry. Being tidal breath-based maneuver, it is more child friendly. People with neuromuscular weakness, cognitive limitations, and the elderly can easily perform it with only minor understanding and effort. Oscillometry is more sensitive than spirometry in detecting peripheral airway diseases. Post-bronchodilator reversibility can be evaluated by comparing with the baseline respiratory characteristics. Their utility in restrictive diseases and vocal cord dysfunction has also been explored. Less aerosol generation during the normal tidal breath is another advantage of oscillometry, over spirometry needing forceful efforts, which makes it more suitable for use in viral pandemic situations for monitoring patients with both asthma and pneumonia. More research is needed, in various geographic locations and heterogeneous populations, to devise the normative data of oscillometric parameters. Simultaneously, there is an urgent need for standardization of available machines at global platform.

Oscillometry – The future of estimating pulmonary functions

Mobile health tracking applications are one of the needed technologies that have a great potential to collect patients’ health history effectively. Contact tracing, symptom tracking and assessment, and health information distribution are among the unmet needs of the healthcare and public health systems, which these apps can address. In this paper, we propose an AIassisted medical diagnosis multiplatform mobile application for lung diseases. The proposed application allows users to track their journey of symptoms as they develop, intensify, and resolve. With a few clicks, the application enables the user to log some symptoms, including headache, cough, and other symptoms and logs other health data like blood pressure and glucose levels automatically from device sensors and wearables through Google Fit integration. Recorded cough sounds are then classified based on spectrogram features using our Convolutional Neural Network on-device cough classifier with an 89% accuracy. Manually input and automatically detected symptoms are added to a timeline that visualizes the user’s symptom history and intensity over time. Users can then navigate the symptom journey themselves or share it with a doctor when needed reducing the need for frequently asked questions by doctors and making it easier to identify and track their symptoms over a long period. Our results show that our proposed application can be used as a diagnostic tool to record symptoms anytime in a few clicks and generate history timelines to track the user’s health. Our user-friendly application is an effective and organized way to document the user’s health status regularly and can be shared with a doctor if necessary.

AI Assisted Medical Diagnosis of Lung Diseases Using Accurate Symptoms Visualization

https://www.pidjournal.com/doi/pdf/10.5005/jp-journals-10081-1239

Protracted Bacterial Bronchitis: An Underdiagnosed Cause for Chronic Wet Cough in Children

Rising air pollution is an ever-growing threat to many human diseases. Poor air quality has been directly correlated with respiratory allergies with a disproportionate affection among the pediatric age group. A clear understanding of common air pollutants and their potential contribution in allergic rhinitis and asthma is lacking. To formulate a consensus statement for appropriate understanding among pediatricians and general practitioners about the effects of air pollution on respiratory allergies and their prevention. A group of experts (Pediatric pulmonologists and allergy specialists) from across India were appointed by the Indian Academy of Pediatrics (IAP) to formulate a consensus statement on ‘Allergy and Air pollution’. A virtual meeting was conducted on 6th April 2020 to discuss in detail regarding various issues related to the subject and a writing committee was formed with broad consensus. After extensive literature review and multiple virtual sessions, the current document was prepared and circulated via email to the representatives from central IAP and IAP environment chapter. All the experts approved the consensus with minor modifications after a detailed discussion on 29th September 2020 on a virtual platform. Air pollution is the emerging contributor to respiratory allergies due to various mechanisms including oxidative stress and compromised mucociliary clearance. Children are more vulnerable to both outdoor and indoor pollution, due to their unique physiological characteristics. Knowledge about pollutant particle size and air quality index will help in demarcating level and extent of airway involvement. Relevant environmental history in difficult allergic rhinitis and asthma cases, along with conventional pharmacological measures, is warranted. Multipronged approach, targeted at community, physician and individual levels, needs to be emphasized to improve air quality and reduce economic and psychological burden of respiratory allergies.

Impact of Air Pollution on Allergic Rhinitis and Asthma: Consensus Statement by Indian Academy of Pediatrics.

other stakeholders like community members, Panchayat Raj Institutions (PRI), Non-Government Organizations (NGO) and other public sector departments as a part of this campaign. Activities from within, like public rallies, marathons, swachhata walks, human chains, street plays/nukkad nataks/folk arts/folkmusic, etc. will act as potent instruments of social advocacy and community participation. It ensures every stakeholder from outside health facility premises and communities are gradually involved for hygiene and infection control and thereby helping health promotion at the grass-root level. World Health Organization estimates that Swach Bharat Abhiyan in India would potentially have a spectacular impact on improving the sanitation of communities and thereby averting disease burden within five years of its launch [4]. The integration and extension of such activities will be another opportunity for healthcare providers to make an impact on health indicators and disease burden. Subsequently, as all stakeholders adopt these initiatives, there will be a visible and viable behavior change of the public at large.

/pdf/spirometry-in-covid-19-times-an-emerging-dilemma-5e4mzzbrp5.pdf

Barnali G Bhattacharya

Papers

Protracted Bacterial Bronchitis: An Underdiagnosed Cause for Chronic Wet Cough in Children

Impact of Air Pollution on Allergic Rhinitis and Asthma: Consensus Statement by Indian Academy of Pediatrics.

Spirometry in COVID-19 Times — An Emerging Dilemma

Knowledge, Attitude, Practices, and Training of Pediatricians in India Regarding Sleep Disorders in Children: A Need to Wake Up!