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27]

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MetHb is formed when iron in the hemoglobin (Hb) changes Conflicts of interest

from ferrous (Fe2+) to ferric (Fe3+) state. In healthy adults, 99% There are no conflicts of interest.
Hb is in Fe2+ state and remaining 1% is MetHb.[1] Increased
fraction of MetHb impairs the oxygen‑carrying capacity of
Hb and hence leads to hypoxemia. MetHb concentration Ankita Chouksey, Alkesh Kumar Khurana,
above 20% is associated with dizziness, fatigue, palpitations Abhishek Goyal
and above 40% is associated with arrhythmias, dyspnea, and
Department of Pulmonary Medicine, All India Institute of Medical
seizures.[1] The diagnosis is usually made by a precipitating/
Sciences, Bhopal, Madhya Pradesh, India
trigger factor in history, and a typical “saturation gap”
E‑mail: [email protected]
between oxygen saturation noted in pulse oximetry and ABG
analysis.[2] Pulse oximetry can detect only oxyhemoglobin REFERENCES
and deoxyhemoglobin. In the presence of MetHb, the oxygen
1. Ward KE, McCarthy MW. Dapsone‑induced methemoglobinemia. Ann
saturation falls when detected via pulse oximetry but not Pharmacother 1998;32:549‑53.
when detected through ABG analysis. This saturation 2. Burke P, Jahangir K, Kolber MR. Dapsone‑induced methemoglobinemia:
gap is very suggestive of the presence of an alternative Case of the blue lady. Can Fam Physician 2013;59:958‑61.
3. Donnelly GB, Randlett D. Images in clinical medicine.
form of Hb, especially MetHb.[2] In addition, the chocolate Methemoglobinemia. N Engl J Med 2000;343:337.
brown color of blood (detected while sampling) is again 4. Ashurst JV, Wasson MN, Hauger W, Fritz WT. Pathophysiologic
indicative of MetHb.[3] Apart from supportive care, specific mechanisms, diagnosis, and management of dapsone‑induced
treatment includes intravenous methylene blue 1–2  mg/ methemoglobinemia. J Am Osteopath Assoc 2010;110:16‑20.
5. Trindade MA, Careta MF. Acute methaemoglobinemia induced by
kg body weight. In vivo, methylene blue is converted dapsone case report in leprosy treatment. Hansenol Int 2008;31:31‑4.
to leukomethylene blue which subsequently acts as
electron donor to MetHb and reduces its concentration.[4]
Hemodialysis may be the last resort in refractory cases.[2]
This is an open access journal, and articles are distributed under the terms of
Methemoglobinemia is an uncommon side effect of dapsone the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
treatment, incidence reported in around 5% of cases. In which allows others to remix, tweak, and build upon the work non‑commercially,
addition, other drugs, namely antimalarials, sulfonamides, as long as appropriate credit is given and the new creations are licensed under
and prilocaine are also reported to cause similar adverse the identical terms.

outcomes which the clinicians should be aware of.[5]

Access this article online
Quick Response Code:
Declaration of patient consent Website:
The authors certify that they have obtained all appropriate www.lungindia.com
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
DOI:
other clinical information to be reported in the journal.
The patients understand that their names and initials will 10.4103/lungindia.lungindia_160_18

not be published and due efforts will be made to conceal

their identity, but anonymity cannot be guaranteed. How to cite this article: Chouksey A, Khurana AK, Goyal A. The girl
with the “saturation gap”. Lung India 2018;35:448-9.
Financial support and sponsorship
© 2018 Indian Chest Society | Published by Wolters Kluwer ‑ Medknow
Nil.

Managing hemoptysis: What to do or what not to do?

Sir, is partly contributed by different causes of hemoptysis,

the common ones being active or healed pulmonary
Hemoptysis is defined as the expectoration of blood tuberculosis  (TB), bronchiectasis, aspergilloma, lung
from the lung parenchyma or airways.[1] It is one of the abscess, and bronchogenic carcinoma. A  systematic
most common and challenging symptom encountered in management protocol needs to be established to focus on
routine clinical practice. Massive or recurrent hemoptysis a more definitive treatment.
is considered to be of major concern that troubles both
patients and the treating physicians. Most physicians A 17‑year‑old male, nonsmoker, resident of Delhi, with no
are facing difficulties in managing this symptom in prior comorbidities presented with cough and recurrent
a systematic and timely fashion because there are hemoptysis for 2  years that increased significantly in
divergent opinions among different physicians regarding volume (often greater than half a cup) for 15 days before
management of massive or recurrent hemoptysis.[2] This admission. He denied any history of fever or night sweats,

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Letters to Editor

breathlessness, and loss of appetite or weight. There were and was advised surgery in view of persistent hemoptysis,
no unusual food or animal exposures. He received empiric significantly restricting young patients’ life; however,
treatment for pulmonary TB (on radiological basis but bilateral disease led to confusion among physicians and
bacteriologically not confirmed) 2 years back for 9 months. surgeons about the side to operate, and he was left on
He did not regularly use any other significant medication wait and watch policy. The patient had no indications
such as aspirin or other nonsteroidal anti‑inflammatory of respiratory distress or stigmata of recent massive
drugs or drug abuse. He had no history of trauma, rash, hemoptysis at the time of admission. His vital signs
kidney disease, hematuria, or known autoimmune were stable: afebrile, blood pressure 120/80  mmHg,
disease. The patient underwent workup for hemoptysis heart rate 92/min, respirations 20/min, and oxygen
at different hospitals and underwent bronchoscopy saturation 96% on room air. Head and neck examination
which was unremarkable, and high‑resolution computed revealed dry mucosa with no evidence of trauma and
tomography (HRCT) thorax showed thick‑walled cavities no lymphadenopathy. Oropharyngeal examination was
in bilateral upper lobes. He was treated conservatively normal. Systemic examination was normal. The patient’s

a b c d

e f g h
Figure 1: (a) Chest skiagram revealed haziness in right (yellow vertical arrow) and left (black vertical arrow) upper lobes. (b‑f) High‑resolution
computed tomography thorax showed small area of cavitation with calcification in apical segment of the right upper lobe as well as apicoposterior
segment of left upper lobe along with surrounding ground‑glass opacity seen exclusively in the left upper lobe (black vertical arrow in e) suggestive of
active source of bleeding. (g and h) The presence of calcified opacity likely broncholith (black horizontal arrow in h) in dilated bronchi communicating
with cavity of left upper lobe especially observed in sagittal section

a b c d

e f g h
Figure 2: (a and b) Gross examination of the resected specimen of lung tissue revealed smooth‑walled cavity measuring 2 cm × 2 cm × 1 cm
with a small broncholith of 0.3 cm (indicated by yellow vertical arrow in a). (c‑h) Microscopic histopathological examination of sections from the
cavity showed granulomas (black vertical arrow in g) with giant cells (white horizontal chevron in d, g, h), foci of calcification (yellow vertical arrow
in f), and mononuclear inflammation suggestive of granulomatous inflammation suggestive of tuberculosis. Lung parenchyma showed alveoli with
hemorrhage and occasional hemosiderin‑laden macrophages (blue horizontal arrow in e) (H and E, ×40 and × 100 respectively)

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Letters to Editor

hemoglobin level was 14.9 g/dL, and the hematocrit was approach in this case, but it is not definitive as probability
41.2%. Rest laboratory parameters including platelet of recurrences are high especially with broncholith as a
count, coagulation as well as vasculitis profile were posttubercular sequelae.[5]
within normal limits. The fecal occult blood test was
negative. Two‑dimensional echocardiography showed a Another issue is that what will be the treatment of
normal ejection fraction and no valvular defect. Chest choice if the same patient reports again with massive or
skiagram revealed nonhomogeneous opacity in the left recurrent hemoptysis from lesion on opposite side, i.e.,
upper lobe. HRCT thorax showed small area of cavitation apical segment of the right upper lobe. It is a matter of
with calcification in bilateral upper lobes along with open debate whether this patient should be treated with
surrounding ground‑glass opacity seen in left upper conservative strategy and observation, bronchoscopic
lobe and a calcified opacity likely broncholith in dilated techniques, BAE, or surgery. All these interventions have
bronchus communicating with cavity of the left upper lobe their own merits and demerits with weak evidence‑based
as shown in Figure 1. Triple‑phase computed tomography support. The choice of treatment depends on several
angiography did not reveal any abnormal vascular origin factors such as age, comorbid illnesses, etiology,
of bleeding. Repeat bronchoscopy confirmed focal pulmonary function status, localization of bleeding,
source of active bleeding from apicoposterior segment response to different methods, and availability or
of the left upper lobe. Bronchoalveolar lavage was taken feasibility of technical expertise.[5] Good clinical practice
from left upper lobe and was freshly hemorrhagic. guides surgical modality to be preferred in clear scenarios,
The microbiological profile including GeneXpert was for example, unilateral disease with good functional
negative for Mycobacterium tuberculosis complex (MTBC). status of the patient and no significant co-morbidities
Case was reviewed with interventional cardiologist tilting risk–benefit ratio in its favor. However, it is
for bronchial artery embolization  (BAE) together with difficult to convince majority of patients for a feasible
thoracic surgical opinion for segmentectomy. Informed option in real life situations despite proper counselling.
decision for surgical option was reached by the family A very intuitive and detailed analysis of each case is
and patient after risk versus benefit of both options were required before assigning an individual option. This
explained in multidisciplinary meeting among all medical has to be decided by a multidisciplinary team including
and family members involved in decision‑making. The clinicians of different specialities. The patients along
patient underwent left apicoposterior segmentectomy with family members should also be made part of the
without any complication and the specimen was sent for team. This will facilitate decision-making process easy
histopathological examination. Gross examination revealed as they will be made well aware of all available options
smooth‑walled cavity measuring 2 cm × 2 cm × 1 cm, with with risk-benefit ratio. In our case, although the patient
a small broncholith of 0.3 cm being the source of bleeding was young and needed to live life without constant fear of
as shown in Figure 2. Microscopic examination showed life‑threatening hemoptysis and had broncholith beyond
evidence of granulomatous inflammation, but GeneXpert reach of bronchoscope, the decision to operate was still
as well as culture was negative for MTBC. The patient was not easy. The patient had multiple hospitalizations and
discharged after 7  days and is under regular follow‑up opinions, but clear advice could not be reached.
for the last 1  year and reported no further episodes of
hemoptysis. There are still many controversies and unresolved issues
regarding the management of massive or recurrent
Such situations are of common occurrence in day‑to‑day hemoptysis from center to center as there is lack of
practice and a matter of concern is that what should have consensus‑based practical guidelines. Various treatment
been the approach if bleeding could not have been localized options are currently practiced depending on the
to broncholith as both lungs had pathological findings in physician’s discretion, expertise, and available resources.[2]
this case? Here, determining the cause and the location Therefore, there is a need to develop guidelines in near
of bleeding becomes an important issue. Mostly patients future for managing massive or recurrent hemoptysis
in our country with bilateral disease are not even sent for systematically and also to emphasize on multidisciplinary
thoracic surgical review. However, scrupulous radiologic as approach. There is urgent need for research in this area,
well as bronchoscopic examinations may provide valuable and we think multidisciplinary approach in all cases with
information regarding surgically correctable cause, recurrent moderate‑to‑severe hemoptysis can only bring
for example, mycotic ball in a cavity or broncholiths[3] best outcomes till then.
even if disease is bilateral, but definitive treatment
remains surgery only. All endobronchial interventions Declaration of patient consent
(e.g., cold saline solution lavage, endobronchial balloon The authors certify that they have obtained all appropriate
tamponade with or without endobronchial instillation of patient consent forms. In the form, the patient has given
epinephrine, bronchoscopic instillation of thrombin or his consent for his images and other clinical information
fibrinogen–thrombin infusion, laser photocoagulation, to be reported in the journal. The patient understands that
endobronchial blockers, and radiotherapy) or BAE are name and initials will not be published and due efforts
temporalizing procedures[4] with surgical therapy being will be made to conceal identity, but anonymity cannot
only “curative.”  BAE could have been an alternative be guaranteed.

Lung India • Volume 35 • Issue 5 • September-October 2018 451

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Letters to Editor

Financial support and sponsorship tuberculosis: The phoenix of thoracic surgery? J Thorac Dis 2013;5:198‑9.
5. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to
Nil.
the management of massive hemoptysis. J Thorac Dis 2017;9:S1069‑86.

Conflicts of interest
There are no conflicts of interest. This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
Abhijeet Singh, Sanjeev Singhal, Nitin Jain, the identical terms.
Deepak Talwar
Access this article online
Division of Pulmonary and Critical Care Medicine, Metro Centre
Quick Response Code:
for Respiratory Diseases, Metro Multi Speciality Hospital, Noida, Website:
Uttar Pradesh, India www.lungindia.com
E‑mail: [email protected]
REFERENCES
DOI:
1. Stedman TL. Stedman’s Medical Dictionary. 28th ed. Baltimore, MD: 10.4103/lungindia.lungindia_82_18
Lippincott Williams & Wilkins; 2006. p. 872.
2. Dixit R, Singh N, Gupta RC. Management issues in haemoptysis:
More questions than answers. Indian J Chest Dis Allied Sci
How to cite this article: Singh A, Singhal S, Jain N, Talwar D.
2013;55:237‑8.
Managing hemoptysis: What to do or what not to do?. Lung India
3. Halezeroğlu S, Okur E. Thoracic surgery for haemoptysis in the context
2018;35:449-52.
of tuberculosis: What is the best management approach? J Thorac Dis
2014;6:182‑5.
© 2018 Indian Chest Society | Published by Wolters Kluwer ‑ Medknow
4. Bertolaccini L, Viti A, Di Perri G, Terzi A. Surgical treatment of pulmonary

Improving primary care physicians’ capacity: A pan India

initiative on management of chronic obstructive pulmonary
disease and asthma

Sir, Ltd. The program was launched with a primary objective

of enhancing knowledge, skills, and core competencies
According to the World Health Organization  (WHO), of PCPs in the management of COPD, asthma, and related
chronic respiratory diseases including asthma and complications. The program has also enabled establishment
chronic obstructive pulmonary disease (COPD) accounted of strong networks between PCPs and specialists, thus
for 4.2 million deaths globally[1] in 2008. The number strengthening the patient referral system. This is an
of people with asthma in India varies between 17 and interdisciplinary, on‑job, 8‑month‑modular program,
30 million patients.[2] According to the WHO (2004), India supported by a panel of 16 national experts, delivered by
witnesses the largest number of asthma deaths (22.3% of 24 pulmonologists across 24 centers and monitored by 19
all global asthma deaths) in the world. With rising burden observers across India.
of COPD and asthma and given its chronicity, primary care
physicians (PCPs) need to be at the forefront for prevention The course pedagogy has been developed after multiple
and management of these conditions. Furthermore, the discussions with multiple stakeholders involved in medical
primary need for PCP involvement in chronic disease education and health‑care delivery system in India. The
management is necessitated by the severe shortage of course content has been discussed in larger forums along
specialists both in rural and urban location. The density of with the updates and feedback of the curriculum received
doctors per lakh population was 64.9 (WHO 100/100,000), throughout the year to keep it evidence based and incorporate
with the urban density four times higher than rural the recent advances. The curriculum includes simple
areas. To address these gaps, Public Health Foundation of diagnostic tests using peak flow meter and spirometer and
India (PHFI) initiated a Certificate Course in Management also correct technique of using the inhaler devices. The
of COPD and Asthma (CCCA) in 2016. content has rich case studies and is evidence based. The
course has been designed to evaluate knowledge gain through
This certificate course is designed and delivered by PHFI tests prior and after each module and through different tools
in collaboration with Chest Research Foundation, Pune, designed specific to the course curriculum. To ensure training
Narayana Health, Bangalore, and is partly supported by an quality and standardized delivery of course curriculum, the
educational grant from GlaxoSmithKline Pharmaceuticals program encompasses a robust monitoring and evaluation

452 Lung India • Volume 35 • Issue 5 • September-October 2018