Invasive mechanical ventilation (IMV) for management of chronic obstructive pulmonary disease (COPD) associated respiratory failure is increasing in Intensive Care Units. However, IMV is not without its own complications. Hence, aim of managing such patients is to get them off the ventilator as early as possible. This bridging process from IMV to extubation is called weaning in which mechanical ventilation is gradually withdrawn and the patient resumes spontaneous breathing. Many objective parameters have been defined for weaning success. Many of these patients are difficult-to-wean because of various pathophysiologic mechanisms that are of particular relevance to patients of COPD. The following review focuses on these mechanisms and how to troubleshoot patients who are difficult-to-wean.

Noninvasive ventilation (NIV) refers to positive pressure ventilation delivered through a noninvasive interface (nasal mask, facemask, or nasal plugs) etc. Over the past decade its use has become more common as its benefits are increasingly recognized. This review will focus on the evidence supporting the use of NIV in various conditions resulting in acute hypoxemic respiratory failure (AHRF), that is, non-hypercapnic patients having acute respiratory failure in the absence of a cardiac origin or underlying chronic pulmonary disease. Outcomes depend on the patient's diagnosis and clinical characteristics. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced team, with careful patient selection, should optimize patient outcomes.

Background: Self-expanding metal stents (SEMS) are a well-accepted treatment modality for malignant tracheobronchial obstruction or malignant tracheoesophageal fistulae (TEFs). The traditional approach to SEMS insertion in central airway obstruction (CAO) has been rigid bronchoscopy performed under general anesthesia. Fluoroscopic guidance is sometimes utilized. Safe and accurate placement of tracheobronchial SEMS has also been described using flexible bronchoscopy. We herein describe our experience with tracheal SEMS insertion using flexible bronchoscopy without fluoroscopic guidance. Methods: A retrospective analysis of the bronchoscopy records was undertaken for the duration June 2012 to June 2014. Patients with malignant CAO or malignant TEF who underwent tracheal SEMS insertion using flexible bronchoscopy were included. Procedures were performed under mild sedation. Fluoroscopic guidance was not utilized. Results: Eleven patients were identified. The mean age was 60.9 (12.8) years. There were 6 males and 5 female patients. Most common indication for tracheal SEMS was CAO (9/11) followed by TEF (2/11). Stent deployment could be accomplished successfully and at the desired location in all the patients. All patients reported immediate symptomatic relief. Two patients experienced peri-procedural respiratory failure that recovered within 24 h. There was no procedure related mortality or other major complications. Conclusion: Insertion of tracheal SEMS in patients with malignant CAO/TEF using flexible bronchoscopy under minimal sedation is a safe and efficacious modality that can be performed without fluoroscopic guidance.

Background: Lung cancer is the most commonly diagnosed and most common cause of death from cancer worldwide. Diagnostic delays continue to remain a common problem, and surgery could be offered in time in <5% of the cases. Aims and Objectives: Assessment of different time intervals from the appreciation of symptoms to final diagnosis and identify probable factors contributing to delay in those intervals. This study will be helpful to find out the obstacle in the lung cancer diagnosis. Settings and Design: Observational cross-sectional tertiary care hospital-based study. Materials and Methods: Fifty cases were collected consecutively according to inclusion and exclusion criteria and assessed based on prefixed questionnaires. Application interval, referral interval, tertiary center interval, and total time to diagnose were measured. Results: Among 50 cases, 36 cases (72%) were male and 14 cases (28%) were female. Mean age was 55.50 years (range 22–81; standard deviation [SD] 12.68). Squamous cell carcinoma was found more in male and adenocarcinoma in female group (Fisher's P 0.0250). Mean application interval mean was 92 days (range 23–210, SD 41.81), mean referral interval 39 days (range 2–160, SD 26.89), mean interval at tertiary center 15 days (range 5–40, SD 8.027), and total interval mean was 146 days (range 45–240, SD 47.33). Among total cases, application delay was in 38 (76%) cases and referral delay in 35 (70%) cases. Median application interval in delay group was 94 days, and in no delay group was 40 days. Among total cases, 35 (70%) were in referral delay group. There was mean referral interval of 50 days and 14 days, respectively among the referral delay and no delay groups. Conclusion: There was maximum delay in application interval. Awareness of lung cancer and level of education along with neglect of a cough as index symptom are the major factors causing application delay. Significant numbers of the patient were not advised computed tomography thorax at the appropriate time and instead received empirical anti-tubercular treatment causing referral delay.

Pulmonary arteriovenous malformation (PAVM) is a rare cause of hemoptysis and exertional dyspnea. Hereditary hemorrhagic telangiectasia is the most common cause of PAVM, but it can also occur in a variety of acquired medical conditions such as postthoracic trauma, cirrhosis of the liver, and conditions causing chronic pulmonary hypertension. We present a case of PAVM with classical cherry aneurysm of right hilar vessels on routine chest X-ray, which led to further evaluation and successful treatment of PAVM by the transseptal closure of the fistula.

A 20-year-old male with 10 years history of treatment for nephrotic syndrome was admitted with 1 month history of fever with chills, productive sputum, pleuritic chest pain, exertional breathlessness, anorexia and 10 days history of vomiting off/on associated with headache. Gram staining of the sputum revealed gram-positive and acid-fast Bacilli by Ziehl–Neelsen staining which had a branching and fragmented morphology suggestive of Nocardia. Computed tomography of the thorax was suggestive of bilateral multiple nodules with cavitation and breakdown and minimal pleural effusion on the right, pleural fluid was turned exudative in nature, and cultures were negative for bacterial and mycobacterial. Contrast magnetic resonance imaging brain revealed multiple nodular lesions in cerebellum and cerebalar hemisphere, the majority of the lesions are showing ring enhancement. Cerebrospinal fluid did not show any abnormality. A provisional diagnosis of disseminated nocardiosis was made. The patient has started a treatment with oral trimethoprim/sulphamethoxazole, injectable ceftriaxone and imipenem for 1 month, and on regular follow–up, he had a marked clinical and radiological improvement.

Chest wall swelling with underlying lung involvement is a rare phenomenon and it poses certain diagnostic challenges as well. It has to be differentiated from other swellings with different underlying etiology. We present a case where a 60-year-old man presented with a progressive chest wall swelling over right sterno-clavicular joint abutting the manubrium sterni. The origin of the swelling resulted from a leak of air from a tense tubercular cavity in the lung parenchyma that was diagnosed with the help of a contrast-enhanced computerized tomography thorax. The case was managed conservatively with antitubercular therapy and evacuation of air from the chest wall swelling by a nasogastric tube.

The rare primitive neuro-ectodermal tumors (PNET) are classically described as tumors of the airways that can metastasize to the pleura. We describe here, a rare case of a PNET originating from the pleura in a 52-year-old, nonsmoker female. The patient presented with clinical features of a right sided pleural effusion. Thoracoscopic pleural biopsy revealed malignant small round cell proliferation consistent with PNET, and the final diagnosis was confirmed by immune-histochemical analysis. Fiberoptic bronchoscopy, contrast enhanced computed tomography chest, and positron emission tomography scan did not reveal any primary lung lesion. The patient underwent pleurodesis for symptom relief but refused any definitive therapy.

The heart is a rare site of metastasis of cancers. Although lung cancer is the most common malignancy worldwide, cardiac metastasis of lung cancer has been rarely described in literature. We describe a patient with lung cancer who presented with metastasis to the left atrium of heart. We also reviewed the literature regarding cardiac metastasis of lung cancer.

We report a rare case of tuberculosis (TB) of base of the tongue following pulmonary TB. Patient presented to us with chief complaints of sore throat, dysphagia, and hoarseness of voice for 20 days. Examination with 90° telescope revealed ulcerative lesion in the base of the tongue on the left side of size 0.5 cm and another lesion in the left arytenoid and inter arytenoid area extending to the false vocal cord of the left side with undermined edges along with whitish slough at the center of the ulcer. Infection of the oral cavity with Mycobacterium tuberculosis is rare, however, it should be considered among the differential diagnosis of the lesions of the oral cavity. The biopsy is necessary to confirm the diagnosis.

Mediastinal lymphadenopathy due to various infective agents such as Mycobacterium and fungus, due to sarcoidosis, lymphoma, and metastasis is often seen. Ordinary bacteria have rarely been reported to cause necrotizing, usually suppurative granulomatous reactions. We report a case of mediastinal lymphadenopathy due to Pseudomonas infection, in a patient of chronic kidney disease on maintenance hemodialysis, who presented with fever, breathlessness, and low blood pressure.