1. Applied Respiratory Physics ............................................................. 1Sk Jindal, VK Jindal

State of matter 1 Physical properties of gases 2 The gas laws 4 Gas solution and tension 6 Vapors 7 Expression of gas volumes and pressures 8 Flow of gases 8

2. Respiratory Function and Mechanics .......................................... 1 1Dheeraj Gupta, Ritesh Agarwal, Ashutosh N Aggarwal

Ventilation 12 Pulmonary circulation 15 Diffusion 17 Ventilation-perfusion (V/Q) relationships 18 Control of ventilation 18

3. History and Physical Examination ............................................... 2 0PR Gupta

History taking 20 History of previous diagnosis and treatment 22 The physical examination 23

4. Pulmonary Function Testing .......................................................... 2 8Ashutosh N Aggarwal

Spirometry 28 Peak expiratory flow 32 Static lung volumes 33 Diffusing capacity of lungs 34 Exercise testing 34 Other tests 35

5. Arterial Blood Gases and Acid Base Balance .......................... 3 7Vinaya S Karkhanis, Jyotsna M Joshi

Arterial blood gas analysis 38 Arterial blood gas interpretation 39 Interpretation of arterial blood gas 44 Pitfalls in arterial blood gas interpretation 45

6. Mycobacteria: An Overview ............................................................ 4 6Romica Latawa, Indu Verma

7. Immunology and Pathogenesis ..................................................... 4 9Krishna K Singh, Indu Verma

Mycobacterium tuberculosis infection and overview ofimmunopathogenesis 49

Immune responses to tuberculosis 51

8. Pulmonary Tuberculosis: Clinical Features and Diagnosis 5 3S Kashyap, Malay Sarkar

Post-primary pulmonary tuberculosis 53 Symptoms and signs 54 Tuberculosis in the elderly 55 Miliary TB 55 HIV and TB 55 Paradoxical response 56

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xx Handbook of Pulmonary and Critical Care Medicine

Physical examinations 56 Diagnosis of tuberculosis 56 Extrapulmonary tuberculosis (EPTB) 60

9. Molecular Diagnosis of Tuberculosis .......................................... 6 1Mamta Kalra, Indu Verma, Suman Laal

Diagnosis of TB 61

10. Management of Tuberculosis ......................................................... 6 6D Behera

Chemotherapy of tuberculosis 66 Rationale for recommended treatment regimens 69 Supervision of chemotherapy 70

11. Antitubercular Drugs ......................................................................... 7 2SK Katiyar, S Katiyar

Isoniazid 73 Rifampicin 75 Streptomycin 76 Pyrazinamide 77 Ethambutol 78 Quinolones 78 Para-aminosalicylic acid 79 Ethionamide/prothionamide 79 Cycloserine 80 Capreomycin 80 Thiacetazone 81 Group 5 drugs 81 Clofazimine 81 Linezolid 82 Amoxicillin/clavulanate 82 Imipenem/cilastatin 82 Clarithromycin 82 High-dose isoniazid 83

12. Prevention of Tuberculosis .............................................................. 8 4Rajesh N Solanki, Ghanshyam B Borisagar, Jitendra A Sisodia

Primordial prevention 84 Primary prevention 84 Secondary prevention 87 Tertiary prevention 90

13. BCG Vaccine ......................................................................................... 9 1PT James

Complications of BCG vaccination 93

14. Extrapulmonary Tuberculosis ........................................................ 9 5Ashok K Janmeja, Prasanta R Mohapatra

Diagnosis 95 Lymph node tuberculosis 95 Pleural effusion 97 Bone and joint tuberculosis 97 Central nervous system tuberculosis 99 Abdominal tuberculosis 100 Genitourinary tuberculosis 102 Skin tuberculosis 103 Miliary tuberculosis 103 Pericardial tuberculosis 104 Hepatic tuberculosis 105

15. Multidrug-resistant Tuberculosis ............................................... 107Surendra K Sharma, Ninoo George

Epidemiology 107

Definition 107 Causes of drug resistance 108 Diagnosis of drug-resistant TB 108 Management 109 Resective thoracic surgery 112 Nutritional support 112 Special situations 113

16. Revised National Tuberculosis Control Programme inIndia—DOTS and DOTS Plus ...................................................... 115D Behera

Revised national tuberculosis control programme 116 Diagnosis of pulmonary tuberculosis 118 Treatment 119 Management of pediatric tuberculosis under RNTCP 122 Management of patients with HIV infection and tuberculosis 123 Multidrug-resistant tuberculosis and DOTS plus 128 Infection control and hospital waste management 129

17. Treatment of Tuberculosis in Special Situations ................. 130Rajendra Prasad

Treatment of tuberculosis in pregnancy and lactation 130 Treatment of tuberculosis in renal insufficiency 131 Treatment of tuberculosis in liver disease 132

18. Tuberculosis and Human Immunodeficiency VirusInfection ................................................................................................ 135SK Jindal

Pathogenesis 135 Clinical effects of HIV on tuberculosis 136 Diagnosis 138 Management 138

19. Nontuberculous Mycobacterial Infections .............................. 142PS Shankar, SK Jindal

20. Community-acquired Pneumonia .............................................. 148Charles Feldman, Ronald Anderson

Microbial etiology of community-acquired pneumonia 148 Risk factors for community-acquired pneumonia 149 Pathogenesis of CAP with particular reference to the Pneumococcus 149 Diagnostic testing 150 Prognosis 151 Treatment of community-acquired pneumonia 152 Prevention of infection—vaccination 154

21. Pulmonary Fungal Infections ....................................................... 155Arunaloke Chakrabarti

Agents responsible 156

22. Pulmonary Mycetoma ..................................................................... 164Alladi Mohan, B Vijayalakshmi Devi, Abha Chandra

Clinical presentation 164 Diagnosis 165 Treatment 166 Prognostic factors 167

23. Nosocomial Pneumonia ................................................................. 168Vishwanathan Gella, SK Jindal

Pathogenesis 168 Diagnosis 169 Risk stratification of patients with VAP 170 Treatment 171 Prevention of HAP and VAP 174

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xxii Handbook of Pulmonary and Critical Care Medicine

24. Viral Pneumonias ............................................................................. 176Arjun Srinivasan, Ritesh Agarwal

Respiratory viruses 176 Presenting features 176 Respiratory protection for health care professionals 180

25. Pulmonary Manifestations of Human ImmunodeficiencyVirus (HIV) Infection ........................................................................ 182Zarir F Udwadia

Pneumocystis jiroveci pneumoniae (PJP) 183 Community-acquired pneumonias (CAPs) 185

26. Lung Abscess ...................................................................................... 187C Ravindran, Jyothi E

Definition 187 Classification 187 Etiology 188 Pathogenesis 188 Clinical features 188 Complications 190 Treatment 191 Prognosis 192

27. Bronchiectasis and Cystic Fibrosis ............................................. 193David Honeybourne

Bronchiectasis 193 Cystic fibrosis 198

28. Rare Respiratory Infections ........................................................... 202Mohankumar Thekkinkattil, S Arulmozhi

Viral infections 202 Bacterial infections 202 Chlamydial infections 203 Zoonotic bacterial pneumonias 205

29. Parasitic Lung Diseases .................................................................. 206VK Vijayan

30. Anaerobic Bacterial Infections of the Lungs and the Pleura .... 214Ashok Shah, Chandramani Panjabi

Pathophysiology 214 Natural history and clinical classification 215 Anaerobes and upper respiratory syndromes 216 Clinical features 217 Laboratory diagnosis 217 Radiological manifestations 218 Treatment 218 Prognosis 219

31. Bronchial Asthma—Epidemiology ............................................. 220SK Jindal

Definition 220 Epidemiology 220 Factors influencing prevalence of asthma 221

32. Allergic Rhinitis, Asthma and Comorbidities ...................... 224Ruby Pawankar, Satoko Kimura, Sachiko Mori, Yukiko Yokoyama

33. Asthma Diagnosis ............................................................................. 228Liesel D’Silva, Parameswaran Nair

Clinical diagnosis 228 Diagnostic challenges 232

34. Control and Management of Stable Asthma ......................... 236Sidney S Braman, David Lee

The goals of asthma treatment 236 Essential components of asthma care 237 Treatment protocols for asthma 240

35. Management of Severe Asthma ................................................... 243Liesel D’Silva, Parameswaran Nair

Managing severe asthma using airway inflammatory markers 245 Monitoring a patient with difficult asthma 246

36. Allergen Desensitization ............................................................... 247Vikram Jaggi

Mechanisms of allergen immunotherapy 247

37. Bronchodilators .................................................................................. 252Samir Malhotra, Nusrut Shafique

Beta-2 adrenergic agonists 252 Methylxanthines (xanthines) 254 Anticholinergic agents 255

38. Childhood Asthma ........................................................................... 257Meenu Singh

Pathophysiology 257 Diagnosis 258

39. Allergic Bronchopulmonary Aspergillosis .............................. 261Ritesh Agarwal

Pathogenesis of ABPA 261

40. Chronic Obstructive Pulmonary Disease:The Neglected Epidemic ................................................................ 268Sundeep Salvi Mortality due to chronic obstructive pulmonary disease 268 Morbidity due to COPD 268 The economic burden of COPD 268 Risk factors for COPD 269 Primary and secondary prevention of COPD 271

41. Health and Economic Burden of Chronic ObstructivePulmonary Disease ........................................................................... 273Monica Barne, Sundeep Salvi

Mortality due to COPD 273 Prevalence of COPD 273 Disability-adjusted life years due to COPD 274 Economic burden of COPD 274

42. Risk Factors for Chronic Obstructive Pulmonary Disease .... 276Sneha Limaye, Sundeep Salvi

Tobacco smoking 276 Indoor air pollution 277 Outdoor air pollution and COPD 277 Occupational exposures 277 COPD associated with pulmonary tuberculosis 278 Chronic asthma as a risk factor for COPD 278 Genetic factors 278 Socioeconomic status 279

43. Pathophysiology of Chronic Obstructive PulmonaryDisease .................................................................................................. 280Bill Brashier, Sundeep Salvi

44. Pulmonary Function Testing in Chronic ObstructivePulmonary Disease (COPD) .......................................................... 285Tavpritesh Sethi, Anurag Agrawal

The clinical need for pulmonary function tests 286 Physiological principles 286 Clinical applications 288 Measuring small airway disease: Impulse oscillometry 291 Other tests 291

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xxiv Handbook of Pulmonary and Critical Care Medicine

45. Systemic Manifestations and Comorbidities ........................ 293SK Jindal, PS Shankar

Pathogenesis 293 Systemic manifestations 293 Therapeutic considerations 296

46. Treatment of Chronic Obstructive Pulmonary Disease ..... 297Peter J Barnes

Risk factors prevention 297 Other drug therapies 303 Nonpharmacological treatments 304 Managing chronic disease 305

47. Acute Exacerbations of Chronic Obstructive PulmonaryDisease .................................................................................................. 306Raja Dhar, AG Ghoshal

Assisted ventilation 311

48. Long-term Oxygen Therapy .......................................................... 314Ritesh Agarwal, SK Jindal

Selection of patients 314 Benefits 315

49. Patient Education in Chronic Obstructive PulmonaryDisease .................................................................................................. 321Tushar Sahasrabudhe

Education about the disease 322 Education to help reduce COPD exacerbations 322 Pulmonary rehabilitation 323 Education and discussion on daily life issues 324 Discussion on special issues 324

50. Smoking/Tobacco Control .............................................................. 326Virendra Singh, Bharat Bhushan Sharma

Smoking control interventions 327

51. Pulmonary Rehabilitation ............................................................. 333Rachael A Evans, Roger S Goldstein

Symptoms and disability associated with chronic obstructive pulmonary

disease 333 The role and definition of pulmonary rehabilitation 334 Future work 340

52. Upper and Central Airway Obstruction ................................... 341VR Pattabhi Raman

Acute UAO 343Chronic UAO 344Therapeutic considerations 350

53. Bronchiolar and Bullous Lung Diseases .................................. 352Gyanendra Agrawal, Dheeraj Gupta

Bronchiolitis 352Bullous disease of the lung 359

54. Approach to Diagnosis of Interstitial Lung Disease ........... 363Dheeraj Gupta

Etiology and classification 363Pathology 365Pathogenesis 365Diagnostic approach 367Management 370Acute exacerbation of ILD 373Prognosis 373

55. Sarcoidosis ........................................................................................... 374Dheeraj Gupta, Om P Sharma

Pathogenesis and immunology 375Pathology 375Diagnosis 378Tuberculosis enigma 380Treatment 381Prognosis and mortality 383

56. Pulmonary Eosinophilic Disorders ............................................ 384Subhash Varma, Aditya Jindal

Pulmonary eosinophilic disorders 385Approach to diagnosis and conclusion 391

57. Infiltrative and Deposition Diseases ........................................ 392Pralay Sarkar, Arunabh Talwar

Pulmonary amyloidosis 392Lysosomal storage disorders 396

58. Climate Change and Lung Disease ........................................... 403Kin Bong Hubert Lam, Jonathan G Ayres

Climate change: An introduction 403Impact of climate change on health 404Climate change and lung disease 404Synergy between air pollution and temperature 406

59. High Altitude Problems ................................................................. 408Ajay Handa

60. Aviation and Space Travel ............................................................ 413Ajay Handa

Air travel 413Space travel 415

61. Diving Medicine ................................................................................ 417Angeline Lazarus, Richard Mahon

Diving physics and physiology 417Types of diving 417Diving-related injuries/illnesses 418Decompression sickness 418Barotrauma 420Nitrogen narcosis 421Pulmonary edema 421Treatment of decompression disorders 421Long-term effects of diving 424

62. Silicosis ................................................................................................. 426PS Shankar, SK Jindal

63. Berylliosis ............................................................................................. 434PS Shankar

Pathogenesis 434Clinical and radiological features 435Diagnosis 435Treatment 436

64. Hard Metal Lung Diseases ............................................................ 437Dilip V Maydeo, Nikhil C Sarangdhar

Etiology and pathogenesis 437Clinical features 438Diagnosis 438Treatment 439

65. The Health Risks of Asbestos Exposure Inhalation ............ 440Daniel E Banks, Harakh V DedhiaAsbestos fibers 440

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xxvi Handbook of Pulmonary and Critical Care Medicine

66. Occupational Asthma ...................................................................... 446Gajanan S Gaude

Work-exacerbated asthma 446Agents causing occupational asthma 446Pathogenetic mechanisms of occupational asthma 449Diagnosis 449Management 451Prognosis 451Prevention 452

67. Hypersensitivity Pneumonitis ..................................................... 453PS Shankar

Definition 453Etiology 453Pathogenesis 453Pathology 455Clinical presentation 455Investigations 456Diagnosis 457Prognosis 457Prevention 458Management 458

68. Toxic Inhalations and Thermal Lung Injuries ....................... 459VK Vijayan, N Goel, R Caroli

Clinical presentations of inhalational injury 459Specific inhaled toxins 461Systemic illnesses from inhaled toxins 464Smoke inhalation lung injury 465Approach to a victim of inhalation injury 466Management 466

69. Drug-induced Respiratory Disease ............................................ 467William J Martin II

Drugs associated with respiratory toxicity 467Diagnosis and management of drug-induced respiratory disease 470

70. Epidemiology and Etiopathogenesis of Lung Cancer ........ 472Navneet Singh

Risk factors 473Molecular biology 476

71. Lung Cancer: Clinical Manifestations ...................................... 479Javaid Ahmad Malik

Local manifestations 479Metastatic manifestations 480Endocrine syndromes 484Neurological syndromes 485Hematological syndromes 487Skeletal 487Miscellaneous syndromes 488

72. Diagnosis and Staging of Lung Cancer .................................... 489Ajmal Khan, Navneet Singh

Diagnosis of lung cancer 489Staging of non-small cell lung cancer 490Staging of small cell lung cancer 492

73. Approach to Management of Lung Tumors ............................ 493Navneet Singh, D Behera

Treatment planning 493Palliation 499

74. Solitary Pulmonary Nodule .......................................................... 502Alladi Mohan, B Vijayalakshmi Devi, Abha Chandra

Terminology 502Etiology 503

Clinical evaluation 503Imaging studies 504Management 508

75. Hematopoietic and Lymphoid Neoplasm of Lungs ............ 509Pankaj Malhotra

Lymphomas 509Lymphomatoid granulomatosis (LYG) 513Secondary involvement of lung by other systemic hematopoietic andlymphoid disorders 513Pyothorax associated lymphomas 515

76. Mediastinal Disorders ..................................................................... 516Arjun Srinivasan, SK Jindal

Imaging of mediastinum 516Mediastinitis 519Tumors and cysts of mediastinum 520Anterior mediastinal mass 521Tumors of the middle mediastinum 523Tumors of the posterior mediastinum 524Tumors of autonomic nervous system 525Superior vena cava syndrome 525

77. Diseases of Thoracic Cage .............................................................. 527Balamugesh T

Kyphoscoliosis 527Pectus excavatum 529Pectus carinatum 529Ankylosing spondylosis 529Obesity 529Flail chest 530Miscellaneous conditions 531

78. Diseases of Diaphragm ................................................................... 533Balamugesh T

79. Diffuse Alveolar Hemorrhage Syndromes, Wegener’sGranulomatosis and Other Pulmonary Vasculitis ................ 537Eleni Stagaki, Vlasis Polychronopoulos

Diffuse alveolar hemorrhage syndromes 537Wegener’s granulomatosis and other pulmonary vasculitides 539ANCA 541

80. Pulmonary Hypertension: A Third World Prospective ...... 545Zeenat Safdar

Clinical features 546Diagnostic evaluation 547Pathophysiology 548Management 549

81. Pulmonary Thromboembolism .................................................... 553Devasahayam J Christopher, Richa Gupta

Pathophysiology 553Risk factors 553Clinical features 554Diagnosis 554Clinical probability assessment 555Assessment of prognosis 555Management 556

82. Pulmonary Vascular Malformations .......................................... 560Gautam Ahluwalia

Investigations 561Management 562Other pulmonary vascular malformations 562

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xxviii Handbook of Pulmonary and Critical Care Medicine

83. Approach to Respiratory Sleep Disorders ............................... 564Ahmed Abdelwahed, Jeremy A Weingarten

Sleep history 564Physical examination for respiratory sleep disorders 566Nocturnal polysomnography 566Portable monitoring 567Sleep questionnaires 567Respiratory disorders during sleep 568

84. Obstructive Sleep Apnea-Hypopnea Syndrome—A Developing Countries’ Perspective ....................................... 570Harmanjit Singh Hira

85. Respiratory Failure ........................................................................... 578Karthik Gnanapandithan, Ritesh Agarwal

Definition 578Classification 578

86. Acute Respiratory Distress Syndrome ...................................... 584Jean I Keddissi, D Robert McCaffree

87. Sepsis ..................................................................................................... 590Sean Eric Hesselbacher, K Guntupally

88. Poisoning, Envenomation and Environmental Injuries .... 601Dhruva Eric Chaudhry, Inder Pal Singh, Deepak Govil

Poisoning 601Stings and envenomation 607Environmental injuries 610

89. Mechanical Ventilation: General Principles and Modes ... 613GC Khilnani, Vijay Hadda

Basic aspects of mechanical ventilation 613Modes of mechanical ventilation 615Newer modes of mechanical ventilation 620Initiating mechanical ventilation 622Complications of mechanical ventilation 624

90. Noninvasive Ventilation ................................................................ 625GC Khilnani, Vijay Hadda

Technical aspect of noninvasive ventilation 625Steps to successful provision of NIPPV 627Clinical uses of NIPPV: Evidence and recommendations 630

91. Blood Gas Monitoring ..................................................................... 633Chandana Reddy, Ritesh Agarwal

Invasive technique 633Noninvasive blood gas monitoring 635

92. Right Heart Catheterization ......................................................... 639Vishal K Patel, Anthony Saleh

93. Nutritional Management and General Care in the IntensiveCare Unit .............................................................................................. 642Navneet Singh

Assessment of nutritional status in critically ill patients 643Goals and principles of nutritional support 644Timing of initiation of nutritional support 644Route of administration of nutritional support 644Quantity and volume of nutrition support 645Delivery of enteral nutrition and its determinants 647General care in ICU 648

94. Airway Management ....................................................................... 650Arjun Srinivasan, Ritesh Agarwal

95. Analgesia and Sedation in the ICU .......................................... 655Karan Madan, Ritesh Agarwal

Initial evaluation and medication reconciliation 655Consequences of off-target sedation and analgesia 656Assessment of pain, sedation and agitation in the ICU: Validated

scales and tools 656Management of analgesia and sedation in the ICU 658

96. Weaning from Mechanical Ventilation ................................... 665Ajmal Khan, Karthik Gnanapandithan, Ritesh Agarwal

Pathophysiology of weaning 665Outcome of weaning 666Assessment for weaning 667Techniques of weaning 668

97. Extracorporeal Life Support for Severe Acute RespiratoryFailure .................................................................................................... 671Stevens Conrad

Patient selection 672Techniques of ECLS 672Vascular cannulation 673Management during support 673Transitioning from ECMO 674

98. Pathophysiology of Pleural Effusion ......................................... 676Srinivas Rajagopala

99. Approach to Pleural Effusion ....................................................... 679George A D’Souza

Mechanisms of pleural effusion formation 679

100. Parapneumonic Effusion and Empyema ................................. 686Devasahayam J Christopher

Definitions 686Pathogenesis 686Epidemiology 687Bacteriology 687Clinical features and diagnosis 687Pleural fluid analysis 688Treatment 688

101. Pneumothorax ..................................................................................... 691Uma Devraj, George A D’Souza

Primary spontaneous pneumothorax 692Secondary spontaneous pneumothorax 697

102. Malignant Pleural Mesothelioma .............................................. 700Arun S Seth, George A D’Souza

Pathogenesis 701Clinical presentation 701Diagnostic approach 702Treatment 703

103. Pulmonary Involvement in Collagen Vascular Disease .... 706Om P Sharma

Rheumatoid arthritis 706Scleroderma 708Sjögren’s syndrome 709Systemic lupus erythematosus 710Dermatomyositis and polymyositis 711Ankylosing spondylitis 712Mixed connective tissue disease 713Treatment 713

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xxx Handbook of Pulmonary and Critical Care Medicine

104. Pulmonary Manifestations of Systemic Diseases:An Approach ....................................................................................... 714Ajmal Khan, SK Jindal

Gastrointestinal diseases 716Hepatic disorders 718Renal diseases 720Other systemic diseases 721

105. Pulmonary Manifestations in Cardiovascular andNeuromuscular Diseases ................................................................ 722Ajmal Khan, SK Jindal

Cardiovascular diseases 722

106. Pulmonary Involvement in Tropical Diseases ....................... 728Sanjay Jain, SK Jindal

Malaria 728Typhoid 730Leptospirosis 731Dengue 732Amebiasis 732

107. Pregnancy and Pulmonary Diseases .......................................... 734Lakhbir Dhaliwal, Preeti Verma

Pulmonary physiological changes during pregnancy 734

108. Rare Lung Diseases .......................................................................... 744Sanjeev Kumar Mehta, PS Shankar

Part I: Pulmonary alveolar phospholipoproteinosis 744Part II: Pulmonary calcification and ossification syndromes 746Part III: Pulmonary alveolar microlithiasis 748

109. End-of-Life Care ................................................................................ 750Jeba S Jenifer, SK Jindal

Prognostication 751Barriers 751Components of end-of-life care 752Common symptoms in end-of-life 752

110. Surgery for Tuberculosis and Infective Lung Conditions ... 755RK Dewan

111. Surgical Aspects of Obstructive Lung Diseases ................... 759Donald Ray Lazarus, Suryakanta Velamuri

Lung volume reduction surgery 759

112. Lung Transplantation ...................................................................... 764Sachin Kumar, Ritesh Agarwal

General indications 764Contraindications 765Waiting list and organ allocation 765Immunosuppressive treatment 767Complications 767Outcomes 771

Index ......................................................................................................................... 773