Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : OC14 - OC18 Full Version

Role of Concurrent use of Thoracic Ultrasonography with 2D Echocardiography among Patients with Commonly Diagnosed Respiratory Illnesses- A Cross-sectional Study


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53489.16212
Amrutha Peter, Jitendra Kishor Bhargava, Amit Kinare, Rekha Agrawal, Brahma Prakash

1. Postgraduate Resident, Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India. 2. Director Professor, Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India. 3. Assistant Professor, Department of Cardiology, NSCB Medical College, Jabalpur, Madhya Pradesh, India. 4. Associate Professor, Department of Radiodiagnosis, NSCB Medical College, Jabalpur, Madhya Pradesh, India. 5. Associate Professor, Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India.

Correspondence Address :
Brahma Prakash,
Associate Professor, Department of Respiratory Medicine, School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India.
E-mail: magicbrahma@rediffmail.com

Abstract

Introduction: Respiratory diseases may affect the functioning of the heart, lung and heart work synchronously. Clinical assessment and work-up of patients with pulmonary problems may need an extension to cardiac disease. Thoracic Ultrasonography (TUS) is a diagnostic modality being used to assess respiratory conditions as it carries the inherent advantages of ultrasonography such as being reliable, inexpensive, safe, reproducible, and having no radiation hazard.

Aim: To assess the usefulness of performing Thoracic Ultrasound (TUS) and 2D Echocardiography in the same sitting, so as to confirm the respiratory diagnosis and to early identify various cardiac dysfunctions in patients with respiratory illnesses.

Materials and Methods: This cross-sectional study was conducted in the Outpatient Department (OPD) of Respiratory Medicine at Netaji Subhash Chandra Bose Medical College (tertiary care hospital), Jabalpur, Madhya Pradesh, India, from January 2019 to March 2020. Patients hospitalised with clinico-radiological diagnosis of pleural effusion, pneumonia, pulmonary fibrosis of interstitial lung disease, pulmonary oedema and Chronic Obstructive Pulmonary Disease (COPD) were subjected to TUS and echocardiography. Sonological findings and cardiac abnormalities were recorded. Data was analysed by applying descriptive statistics, t-test, and Chi-square test. A p-value <0.05 was considered as statistically significant.

Results: A total of 133 patients were enrolled with diagnosis of pleural effusion (n=46), COPD (n=33), pneumonia (n=22), pulmonary fibrosis (n=18) and pulmonary oedema (n=14). Out of total 46 patients, 36 patients with pleural effusion had cardiac findings. The presence of pleural effusion showed a significant association with cor-pulmonale (p-value=0.012), dilated Right Ventricle (RV) (p-value=0.012), septal deviation (p-value=0.012), Pulmonary Hypertension (PH) (p-value=0.0002), Left Ventricular (LV) dysfunction (p-value=0.02) and Left Ventricular Ejection Fractions (LVEF) (p-value=0.006). The focal B-lines were seen in patients with pneumonia. Patients with Pulmonary fibrosis had scattered B-Lines, and patients with pulmonary oedema had bilateral diffuse B-lines. Among patients with pulmonary fibrosis, 11 (61.1%) had cor-pulmonale and dilated RV, whereas 10 (55.5%) had septal deviation. Patients with scattered B-lines more commonly had PH. In patients with COPD, cor-pulmonale was detected in 21 (63.6%), LV dysfunction in 5 (15.1%), mild PH in 14 (42.4%), moderate PH in 7 (21.2%), and severe PH in 5 (15.1%) using echocardiography.

Conclusion: This study reveals the importance of performing a combination of TUS with 2D Echocardiography and suggests its usefulness in early diagnosis of cardiac dysfunctions in patients with various respiratory illnesses.

Keywords

Cor-pulmonale, Dilated right ventricle, Pleural effusion, Pulmonary fibrosis, Septal deviation

Any disease that affects the lung may have an effect on the functioning of the heart and vice-versa (1). Clinical assessment and work-up of patients with pulmonary problems may need an extension to cardiac disease. Thoracic Ultrasonography (TUS) is a diagnostic modality being used to assess respiratory conditions as it carries the inherent advantages of ultrasonography such as being reliable, inexpensive, safe, reproducible, and having no radiation hazard. Also, guided procedures such as aspiration of fluid-filled areas and solid tumors can be done using it. This procedure aids in the better assessment of the surface of the lung through the intercostal spaces rather than the examination of deeper thoracic structures limited by the presence of ribs and air in the expanding lung (2). The TUS in critical care settings can help in the evaluation of acute dyspnoea, pulmonary embolism, for diagnosis of pleural effusion, pneumothorax, and pneumonia. It can also help in differentiating cardiogenic from non cardiogenic pulmonary oedema (3). The TUS can also be considered for a quick and reliable assessment of decompensation in patients with heart failure (4).

On the other hand, echocardiography is an equally important diagnostic tool in respiratory care for the immediate evaluation of patients with cardiopulmonary failure. It is a bedside investigation that can establish an initial diagnosis and serial examinations may be performed to guide ongoing management. It helps to evaluate the cardiac function both systolic and diastolic that can be compromised.

The concurrent use of TUS may be important along with echocardiography in especially those respiratory conditions that are known to have cardiac complications or cardiac associations. It will be also useful if patients are subjected to these two non invasive investigations at the time of presentation, as it can help in providing an immediate diagnosis and thereby making quick patient management possible without the need for any sophisticated investigations. The incorporation of Electrocardiography (ECG) and echocardiographic information, addressing to the clues of right ventricular impairment, pulmonary embolism and PH, and other less frequent conditions like congenital, inherited and systemic disease, usually allows more timely diagnosis.

The concomitant use of TUS is important, because, despite the evidence of the clear links between respiratory and cardiac illnesses, heart and lung ultrasonography imaging approaches are still isolated. Echocardiography is an investigation which also helps to study and monitor several respiratory conditions and helps even in its detection, so that this is now-a-days an established functional complementary tool in pulmonary fibrosis and diffuse interstitial disease diagnosis and monitoring. It is also important that cardiologist extend their approach to lung and pleura which will give information on pleural effusion, even minimal, lung consolidation and pneumothorax (5).

Some studies recommend the complimentary use of echocardiography improve the diagnostic accuracy of TUS in patients with Acute Respiratory Failure (ARF) (6),(7). This approach was found to be particularly important in cases of acute haemodynamic pulmonary oedema and pneumonia, highlighting the unavoidable place of echocardiography in the diagnosis and management of ARF (8). The addition of TUS to echocardiography provides an additive insight into the eventual pulmonary involvement. The cardiopulmonary system is so inter-connected, that an integrated approach is mandatory. The TUS help in identifying those patients who, although asymptomatic, but would decompensate and require more aggressive treatment. The use of TUS along with echocardiography would require only a few minutes in addition to the time needed for either of these investigations alone (9). Hence, this study aims to assess the usefulness of performing TUS and 2D Echocardiography in the same sitting, so as to confirm the respiratory diagnosis and to early identify various cardiac dysfunctions in patients with respiratory illnesses.

Material and Methods

This cross-sectional study was conducted in the Outpatient Department (OPD) of Respiratory Medicine at Netaji Subhash Chandra Bose Medical College (tertiary care hospital), Jabalpur, Madhya Pradesh, India, from January 2019 to March 2020. Prior to initiating the study, ethical clearance was taken from the Institutional Ethics Committee in a meeting held on (Letter No. IEC/2021/8447). A duly informed written consent from study subjects was taken before the enrollment. The subjects enrolled into study did not had extra cost burden due to these tests, since the patients were managed free of cost after waiving off test charges.

Inclusion criteria: Patients were diagnosed {pleural effusion, pneumonia, interstitial pulmonary fibrosis, non cardiogenic pulmonary oedema and Chronic Obstructive Pulmonary Disease (COPD)} on the basis of history, clinical examination, chest x-ray, and lung function test such as spirometry and Diffusing capacity of the Lungs for Carbon Monoxide (DLCO). In the present study, patients with interstitial pulmonary fibrosis graded to have moderate to severe restrictive lung disease in spirometry and moderate to severely reduced DLCO. The patients with COPD belonging to Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade 2, 3 or 4 severity of airflow limitation/GOLD group C or D (10) without any known cardiac co-morbidities were included for the study participation, since mild category of such cases most of the time are managed on outpatient basis of the hospital.

Exclusion criteria: Patients who had already diagnosed with cardiac diseases, aged less than 18 years of age, pregnant women and those patients who were critically ill and admitted under intensive care units were excluded from the study. The patients who were unwilling for undergoing TUS or echocardiography test were also excluded for the study.

Procedure?

Thoracic ultrasound

All these patients offered TUS test for further evaluation as part of routine workup, using DC-30 Mindray machine with colour Doppler, a linear probe of frequency 7.5-10 MHz, and a curvilinear probe of frequency 2-5 MHz to achieve a maximum area of thorax scanning.

15The TUS was performed in different positions such as supine, lateral decubitus, or prone. The probe was positioned both longitudinally, perpendicular to the ribs, and obliquely, along with the intercostal spaces, to see various radiological signs in lung sonography. Assessment for presence of pleural effusion, distribution of B-lines, if any, for assessing pulmonary fibrosis and pneumonia, air-bronchogram or fluid-bronchogram for confirming presence of pneumonia was done. In patients with COPD, a 2-2.5 MHz phased array transducer was used to assess the diaphragmatic excursion in M-mode. Subsequently, all the study subjects underwent an echocardiography using HD7XE Philips machine with colour doppler, with monitor size 15” and the 5 MHz transducer (probe), irrespective of any history suggestive of cardiac illness. Two dimensional, M-mode and colour doppler echocardiography was performed, with the patient in supine and left lateral decubitus. An expert radiologist and cardiolgist performed the TUS and echocardiography respectively in all the study participants.

2D Echocardiography

In this study, normal 2D Echocardiography measurements were as follows:

• Left Ventricular End Diastolic Diameter (LVEDD) (37-57 mm)
• Left Ventricular End Systolic Diameter (LVESD) (14-21 mm)
• Aortic Roots (2.3-3.7 cm)
• Left Atrium (1.9-3.4 cm)
• Right Ventricle (0.7-2.3 cm)
• Interventricular septal thickness was measured at the end of diastole as well as systole (7-11 mm)
• Thickness of LV posterior wall was taken at the end of diastole as well as systole (7-11 mm)
• Left Ventricle Ejection Fraction (LVEF) was calculated as follows: LVEF%=(LVEDD3-LVESD3×100)/LVEDD3
• Mild Pulmonary Hypertension (PH): Pulmonary Artery Systolic Pressure (PASP) 30-50 mmHg
• Moderate PH: PASP >50-70 mmHg
• Severe PH: PASP >70 mmHg (11)

The echocardiographic features suggestive of cor-pulmonale and those with isolated findings of dilated Right Atrial (RA), dilated Right Ventricle (RV), septal deviation, LV dysfunction or PH were reported separately. In our study PASP was estimated using Right Ventricular Systolic Pressure (RVSP). Doppler echo was used to calculate RVSP in the presence of tricuspid regurgitation jet. RVSP=4V2+RAP (Modified Bernoulli equation) (12), where ‘v’ is the velocity of tricuspid jet in meters per second and Right Atrial Pressure (RAP) was assessed from echocardiographic features of inferior vena cava. The PASP is assumed to be equal to RVSP when the pulmonic valve is normal.

Statistical Analysis

All the information collected during these tests were recorded in a structured proforma, and then statistical analysis was done using the software IBM Statistical Package for the Social Sciences (SPSS) version 23.0 for windows. Range, frequencies, percentage, mean, standard deviation was used wherever applicable. Students t-test was used for comparison of means and Chi-square test was used to analysis difference in categrorical variable. The p-value <0.05 was considered as statistically significant.

Results

A total of 133 patients were enrolled during the study period. The majority were in the age group of 51-60 years, and 60.2% of participants were males. Pleural effusion and COPD were the two most frequent diagnosis (Table/Fig 1).

The patients with a clinico-radiological diagnosis of pleural effusion underwent TUS. TUS could confirm pleural effusion in all the patients (bilateral pleural effusion in 16, right sided pleural effusion in 19, and left sided pleural effusion in 11).

These patients underwent ultrasound-guided pleural fluid aspiration, on the basis of Light’s criteria, the pleural effusions were categorised into transudative and exudative pleural effusion. Among these patients, 25 had transudative effusion and 21 had exudative effusion. Among the transudative type of pleural fluid, bilateral effusion was seen in 12, right sided in 7 and left sided effusion in 6 cases respectively, whereas the right sided pleural effusion was most common in exudative type of pleural fluids (12 out of 21 cases). The frequency of the cardiac findings in these two types of pleural effusion is shown in (Table/Fig 2).

Various cardiac findings in the patients of pleural effusion, subdivided into transudate and exudate pleural effusion, are shown in (Table/Fig 3). Among the cardiac finding detected using echocardiography, both transudative and exudative pleural effusions had significant association with cor-pulmonale, dilated RV, septal deviation, PH, and LV dysfunction (p-value <0.05), but cardiac findings of Right Ventricular Hypertrophy (RVH) and pericardial effusion had no statistically significant association with pleural effusion. Among 25 patients with transudative pleural effusion, only two patients had findings of mild PH, whereas among 21 patients with exudative pleural effusion 10 patients had mild PH. Moderate to severe PH was not seen in any of the two groups of patients with pleural effusion. There was also a statistically significant difference of means of LVEF between transudative and exudative type of pleural effusion (Table/Fig 4).

The characteristic focal B-lines and air bronchograms seen on TUS confirmed the presence of 22 cases of pneumonia, 18 patients of pulmonary fibrosis had scattered B-lines and 14 patients of pulmonary oedema had diffuse bilateral B-lines. Among 22 patients with pneumonia (focal B-lines) and 14 patients with pulmonary oedema (bilateral diffuse B-lines), none had cor-pulmonale, dilated RV, or septal deviation. Among 18 patients with pulmonary fibrosis (scattered B-lines), 11 patients had cor-pulmonale and dilated RV and 10 had septal deviation. Among 22 patients with pneumonia, one patient had mild PH. Among 18 patients with pulmonary fibrosis, 5 patients had mild PH, three had moderate PH and 4 had severe PH. Among 14 patients with pulmonary oedema, two patients had mild PH and one patient had moderate PH. Apart from patients with pulmonary fibrosis and pulmonary oedema, one patient with pneumonia had echocardiographic features suggestive of cardiac involvement. The presence of B- lines or air-bronchogram was confimed in remaining 21 patients with pneumonia without any other cardiac involvement. The findings shows that patients with chronic parenchymal lung diseases have more cardiac dysfunctions, compared to acute diseases like pneumonia (Table/Fig 5).

There is a statistically significant association between TUS detected B-lines and dilated RV, cor-pulmonale, septal deviation, RV hypertrophy and PASP (p-value <0.005). None of the patients in this study, with TUS detected B-lines had regional wall motion abnormality and pericardial effusion in 2D echocardiography.

Among the 33 patients with COPD, 23 patients belonged to GOLD group-C and remaining 10 patients belonged to GOLD group-D. All patients with COPD had decreased diaphragmatic excursion and 27 patients had reduced diaphragmatic thickness (23 with GOLD group-C and four with GOLD group-D) noted in M-mode ultrasonography. Of these patients cor-pulmonale was detected in 21 patients (63.6%) and five patients (15.1%) had LV dysfunction. Of these five patients with LV dysfunction, three had moderate LV dysfunction, one had mild and one had severe LV dysfunction. Among 33 patients with COPD, seven patients (21.2%) had no PH, 14 (42.4%) had mild PH, 7 (21.2%) had moderate PH and 5 (15.1%) had severe PH. Seven patients with COPD also had regional wall motion abnormality on 2D echocardiography. The frequency of these cardiac findings in echocardiography in patients with COPD is shown in (Table/Fig 5).

Discussion

Congestive Heart Failure (CHF) represents the most common cause of transudative pleural effusions, present in 50% to 90% of patients admitted for CHF [13-15]. LV failure is considered an essential factor for producing effusions (16). In the present study, 36 out of a total of 46 patients with pleural effusion had some cardiac findings detected on echocardiography. Among the patients having transudative pleural effusion in this study, 72% (18/25) had cardiac abnormalities.

Although Congestive Heart Failure (CHF) is the most common cause of bilateral pleural effusions (60-85%); unilateral effusions are more commonly right sided, right-to-left ratio being 2:1 (17). In present study, also 75% (12 out of 16) of pleural effusion in the transudative category were bilateral in location. Among the remaining 4 patients with LV failure, 2 had right sided and 2 had left sided transudative pleural effusion. However, it has been discovered that approximately 25% of cases of pleural effusion of uncomplicated heart failure can be exudatve in nature, which can be distributed bilaterally worse on any side (18),(19). In the present study, it was found that 16% of patients with exudative pleural effusion had uncomplicated LV dysfunction. Another co-existing condition of pericardial effusion along with pleural effusion has been commonly observed in patients having uncomplicated heart failure, which was also seen in the patients (n=12) who had transudative pleural effusion along with LV dysfunction in the present study.

The presence of B-lines on TUS with varying distributions is seen in various lung parenchymal disorders. Pulmonary fibrosis being one of the very common condition seen in patients with interstitial lung disease. In them, scattered B-lines are seen on TUS. The cardiovascular manifestations of Idiopathic Pulmonary Fibrosis (IPF) include PH, heart failure, Coronary Artery Disease (CAD), cardiac arrhythmias and cardiac side-effects of drugs used to treat IPF (20). Among these Right Heart Failure (RHF) are very severe complications of IPF and contribute significantly to patient morbidity and mortality in IPF (21). Despite this, PH in IPF is not well studied at an early stage of IPF, until the fibrosis becomes quite severe (22).

Right Heart Catheterisation (RHC), is considered to be the gold standard in the diagnosis of PH of any cause, but it is invasive and inconvenient which has made it hard to study PH-IPF in longitudinal studies. Lastly, most of the data that is available about PH-IPF comes from a small cohort of patients who are referred for lung transplantation evaluation, which does not represent all patients with IPF. Echocardiography has been considered to be not a very specific test to detect PH as the accuracy of diagnosis of PH in IPF with transthoracic echocardiogram has been seriously questioned. The PH in IPF has been found in around 10-32% of patients in various clinical studies, but they have used the RHC for diagnosing PH (23),(24).

Confirming PH with RHC have technical and logistics issues in developing countries like ours, where echocardiography is a helpful tool, with an added advantage, of that, it can be applied at an early stage of IPF and detect early PH with IPF. In the present study, PH was detected in 12 out of 18 (66%) patients with Pulmonary fibrosis in echocardiography, although th test being non specific, none of the echocardiography screened patients could be subjected for RHC for confirmation, due to logistic constraints and clinical settings in which this study had been done.

There is a high prevalence of cardiovascular co-morbidities which are associated with considerable morbidity and mortality in patients with COPD (25). They have two-to three-fold increased cardiovascular morbidity and mortality risk compared to non COPD patients (26). This has been associated with disease severity, and systemic inflammation is seen to be particularly important (27). As cardiac abnormalities contribute to the overall morbidity associated with COPD, a clear understanding of their role and potential for treatment is vital. Echocardiography plays a key role in the diagnostic and therapeutic work-up of these patients as a valuable tool for tracking right ventricular function in patients with cor-pulmonale, helps in assessing its stability, deterioration, or improvement during follow-up (28). Echocardiographic evaluation on a timely basis has a pivotal role in early detection of various cardiovascular alterations in COPD like PAH, LV or RV dysfunction, TR, and cor-pulmonale (29).

Although COPD patients are known to have cardiac co-morbidities, none of the enrolled patients had any known cardiac illness history prior to enrollment in the study. As TUS and 2D Echocardiography was used concurrently in this study and the cardiac co-morbidities were detected. These patients could have been missed if the concurrent 2D echocardiography was not done in the patients being assessed only for pulmonary findings on TUS.

Limitation(s)

The main limitation of the present study was the small sample size as it was carried out within a fixed period of time, operator skill dependant, therefore the possibility of variation in subjective interpretation of findings, cannot be ruled out. These tests cannot surely eliminate the need of further advanced investigations, that may be necessary for complete evaluation of such patients.

Conclusion

From the present study, it was concluded that TUS along with 2D Echocardiography is useful in early confirmation of diagnosis. A combination of TUS with 2D Echocardiography in the same sitting in cases of pleural effusion yields better diagnostic accuracy. Cardiac involvement in diseases like pulmonary fibrosis, pulmonary oedema, and COPD could be detected early with the use of 2D Echocardiography and TUS. This would assist in diagnostic work-up plan and this may contribute in better patient management.

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DOI and Others

DOI: 10.7860/JCDR/2022/53489.16212

Date of Submission: Dec 01, 2021
Date of Peer Review: Jan 04, 2021
Date of Acceptance: Feb 02, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 02, 2022
• Manual Googling: Jan 27, 2022
• iThenticate Software: Jan 29, 2022 (13%)

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