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Resolution of asthmatic symptoms following successful endoscopic resection of tracheal mucoepidermoid carcinoma

Hanif Khan A, Faisal M, Mohd Ali R, Abdul Rahaman JA

BMJ Case Rep, 2019 Jan 17;12(1).
PMID: 30659001 DOI: 10.1136/bcr-2018-226202

Mucoepidermoid carcinoma (MEC) is a rare tumour of the trachea accounting for up to 0.2% of reported primary lung malignancy. We report a case of a 54-year-old man, ex-smoker, whose presentation mimicked adult onset asthma with cough and wheezing, which did not respond to conventional treatment. He had occasional haemoptysis and weight loss in which CT scan performed for malignancy screening showed a protruding mass in the distal trachea causing endobronchial obstruction. Bronchoscopic intervention was performed to relieve the obstruction that resulted in resolution of asthmatic symptoms. Histological diagnosis confirmed MEC. This case emphasised the importance of a high index of suspicion in an unusual presentation of a common disease and the pivotal role of bronchoscopic intervention in malignant central airway obstruction.
Virtual Bronchoscopic Navigation Guided Recanalization of Chronic Total Post-Tuberculosis Bronchial Stenosis

Kho SS, Nasaruddin MZ, Abdul Rahaman JA

Arch Bronconeumol, 2022 Nov;58(11):768-769.
PMID: 35606265 DOI: 10.1016/j.arbres.2022.05.003
Fulltext Tuberculosis in adults

Abdul Rahaman JA, Ker HB, Yusof M, Hanafi NS, Wong JL

Malays Fam Physician, 2014;9(3):34-7.
PMID: 26425303 MyJurnal

Tuberculosis (TB) in Malaysia is rising due to multiple factors and issues related to its management are addressed in the updated evidence-based clinical practice guidelines. Screening for active TB should be considered in high risk groups. Light emitting diode-based fluorescence microscopy and nucleic acid amplification tests are recommended investigations. Health education and standardised 6-month daily antituberculosis (antiTB) regimen are among important elements for successful treatment. Latent TB infection screening should only be performed on high risk individuals. AntiTB regimen offered to HIV-positive adults should be the same as for HIV-negative adults and timing to initiate highly active antiretroviral therapy in patients with TB is based on CD4 count. All patients on antiTB treatment should be monitored to assess their response to treatment and to identify problems associated with it.
Fulltext Treatment of multiple-level tracheobronchial stenosis secondary to endobronchial tuberculosis using bronchoscopic balloon dilatation with topical mitomycin-C

Faisal M, Harun H, Hassan TM, Ban AY, Chotirmall SH, Abdul Rahaman JA

BMC Pulm Med, 2016;16(1):53.
PMID: 27080697 DOI: 10.1186/s12890-016-0209-1

Tracheobronchial stenosis is a known complication of endobronchial tuberculosis. Despite antituberculous and steroid therapy, the development of bronchial stenosis is usually irreversible and requires airway patency to be restored by either bronchoscopic or surgical interventions. We report the use of balloon dilatation and topical mitomycin-C to successful restore airway patency.
Development and Practical Application of a Multiple-Criteria Decision Analysis Framework on Respiratory Inhalers: Is It Always Useful in the MOH Malaysia Medicines Formulary Listing Context?

Yong YV, Mahamad Dom SH, Ahmad Sa'ad N, Lajis R, Md Yusof FA, Abdul Rahaman JA

MDM Policy Pract, 2021 03 30;6(1):2381468321994063.
PMID: 33855190 DOI: 10.1177/2381468321994063

Objectives. The current health technology assessment used to evaluate respiratory inhalers is associated with limitations that have necessitated the development of an explicit formulary decision-making framework to ensure balance between the accessibility, value, and affordability of medicines. This study aimed to develop a multiple-criteria decision analysis (MCDA) framework, apply the framework to potential and currently listed respiratory inhalers in the Ministry of Health Medicines Formulary (MOHMF), and analyze the impacts of applying the outputs, from the perspective of listing and delisting medicines in the formulary. Methods. The overall methodology of the framework development adhered to the recommendations of the ISPOR MCDA Emerging Good Practices Task Force. The MCDA framework was developed using Microsoft Excel 2010 and involved all relevant stakeholders. The framework was then applied to 27 medicines, based on data gathered from the highest levels of available published evidence, pharmaceutical companies, and professional opinions. The performance scores were analyzed using the additive model. The end values were then deliberated by an expert committee. Results. A total of eight main criteria and seven subcriteria were determined by the stakeholders. The economic criterion was weighted at 30%. Among the noneconomic criteria, "patient suitability" was weighted the highest. Based on the MCDA outputs, the expert committee recommended one potential medicine (out of three; 33%) be added to the MOHMF and one existing medicine (out of 24; 4%) be removed/delisted from the MOHMF. The other existing medicines remained unchanged. Conclusions. Although this framework was useful for deciding to add new medicines to the formulary, it appears to be less functional and impactful for the removal/delisting existing medicines from the MOHMF. The generalizability of this conclusion to other formulations remains to be confirmed.
A nationwide survey on awareness and knowledge about Bronchial Provocation Test amongst doctors in Malaysia

Ng KL, Huan NC, Mohammad FA, Mohd Aminudin NH, Mohammad FA, Abdul Rahaman JA

Med J Malaysia, 2022 Jan;77(1):33-40.
PMID: 35086992

BACKGROUND: Bronchial provocation test (BPT) is widely used internationally not only to evaluate bronchial responsiveness in conditions especially asthma, but is also utilized as a marker of control, severity and prognosis for asthma. However, the uptake of BPT in certain countries including Malaysia remains low. We aimed to explore this lack of knowledge by assessing the current level of awareness and knowledge on BPT amongst doctors in Malaysia.
MATERIALS AND METHODS: A nationwide web-based questionnaire targeting doctors was sent through social media (Facebook, WhatsApp and Telegram) and Malaysian Medical Association (MMA) mailing lists between 1 October 2020 - 5 February 2021.
RESULTS: In all 415 survey responses were analysed from doctors of various grades namely medical officers to consultants. A total of 404 (97.35%) encountered patients with asthma in their daily practice. According to specialty: 169 (40.72%) were from primary care, 121 (29.16%) internal medicine, 50 (12.05%) pulmonary medicine and 75 (18.07%) others. Only 163 (39.28%) were aware of BPT as a tool to diagnose asthma. 232 (55.90%) and 124 (29.88%) regarded BPT as an important test and felt confident to refer patients for BPT respectively. Of those participants who were not confident to refer: 35.17% were unsure of BPT indications, 33.21% were unsure of centres providing BPT, 8.17% cited logistic reasons, 6.04% were concerned of possible BPT side effects. 387 (93.25%) wanted more training in BPT. The median BPT knowledge score was 20% (1 out of 5). Awareness and knowledge were affected by specialty but not by: region of practice, gender, age and grade from logistic regression analysis.
CONCLUSION: Various national level programs and targeted local interventions are much needed to increase the awareness, knowledge and uptake of BPT in Malaysia.
Fulltext The more you give, the worse it gets

Kho SS, Nyanti LE, Muhammad NA, Nasaruddin MZ, Abdul Rahaman JA

Breathe (Sheff), 2021 Sep;17(3):210083.
PMID: 35035553 DOI: 10.1183/20734735.0083-2021

Persistent tachypnoea despite resolution of bronchospasm in a patient with acute asthma exacerbation after administration of inhaled short acting β2-receptor agonist should alert the clinician to this potential diagnosis. https://bit.ly/385VU2Q.
Fulltext Silicone Y-stent insertion under extracorporeal membrane oxygenation (ECMO) in a patient with tracheal tear

Mohd Esa NY, Faisal M, Vengadesa Pilla S, Abdul Rahaman JA

BMJ Case Rep, 2020 Dec 22;13(12).
PMID: 33370965 DOI: 10.1136/bcr-2020-236414

Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.
Fulltext Successful drainage of complex haemoserous malignant pleural effusion with a single modified low-dose intrapleural alteplase and dornase alfa

Ng BH, Mohd Aminudin NH, Nasaruddin MZ, Abdul Rahaman JA

BMJ Case Rep, 2021 Feb 05;14(2).
PMID: 33547099 DOI: 10.1136/bcr-2020-239702

Patients with symptomatic complex malignant pleural effusion (MPE) are frequently unfit for decortication and have a poorer prognosis. Septations can develop in MPE, which may lead to failure of complete drainage and pleural infection. Intrapleural fibrinolytic therapy (IPFT) is an alternative treatment. The use of IPFT in patients with anaemia and high risk for intrapleural bleeding is not well established. We report a successful drainage of complex haemoserous MPE with a single modified low-dose of intrapleural 5 mg of alteplase and 5 mg of dornase alfa in a patient with pre-existing anaemia with no significant risk of intrapleural bleeding.
Clinical and radiological outcomes of SARS-CoV-2 related organising pneumonia in COVID-19 survivors

Kho SS, Lim KC, Muhammad NA, Nasaruddin MZ, Ismail I, Daut UM, et al.

Med J Malaysia, 2023 Mar;78(2):131-138.
PMID: 36988520

INTRODUCTION: COVID-19 patients frequently demonstrate radiological organising pneumonia (OP) pattern. The longterm outcome and treatment options for this group of patients remain uncertain. We aim to describe the clinical and radiological outcomes of patients with COVID-19-related OP and identify possible clinical factors associated with inferior radiological outcome.
MATERIALS AND METHODS: Post-COVID-19 clinic attendees, consisting of post-COVID-19 patients discharged from major hospitals in the state of Selangor during the third pandemic wave of COVID-19 in Malaysia, were enrolled in this retrospective study for 6 months. Physician-scored Modified Medical Research Council (mMRC), patient self-reported quality of life (EQ-VAS) score and follow-up CT scan were evaluated.
RESULTS: Our cohort comprised 131 patients, with a median age of 52 (IQR 39-60) years and median BMI of 29.40 (IQR 25.59-34.72). Majority (72.5%) had co-morbidities, and 97.7% had severe disease requiring supplementary oxygen support during the acute COVID-19 episode. 56.5% required intensive care; among which one-third were invasively ventilated. Median equivalent dose of methylprednisolone prescribed was 2.60 (IQR 1.29-5.18) mg/kg during admission, while the median prednisolone dose upon discharge was 0.64 (IQR 0.51-0.78) mg/kg. It was tapered over a median of 8.0 (IQR 5.8-9.0) weeks. Upon follow-up at 11 (IQR 8-15) weeks, one-third of patients remained symptomatic, with cough, fatigue and dyspnoea being the most reported symptoms. mMRC and EQ-VAS scores improved significantly (p<0.001) during follow-up. Repeat CT scans were done in 59.5% of patients, with 94.8% of them demonstrating improvement. In fact, 51.7% had complete radiological resolution. Intensive care admission and mechanical ventilation are among the factors which were associated with poorer radiological outcomes, p<0.05.
CONCLUSION: Approximately one-third of patients with SARSCoV- 2-related OP remained symptomatic at 3 months of follow-up. Majority demonstrated favourable radiological outcomes at 5-month reassessment, except those who required intensive care unit admission and mechanical ventilation.
Fulltext Inflammatory endobronchial polyps unleashing recurrent pneumothorax: A case report

Daut UN, Faisal Thena MH, Hui-Xin T, Nasaruddin MZ, Abdul Rahaman JA

Respirol Case Rep, 2024 Jan;12(1):e01278.
PMID: 38239333 DOI: 10.1002/rcr2.1278

Inflammatory endobronchial polyps (IEPs) are rare benign lesions that originate from the bronchial mucosa. While pneumothorax is a well-known complication of various pulmonary conditions, its association with IEPs is exceedingly uncommon and poorly understood. This case report presents a unique and explosive encounter of a patient with an inflammatory endobronchial polyp who experienced a pneumothorax, shedding light on the clinical presentation, diagnostic challenges, and management strategies for this rare entity.
Fulltext Pulmonary mucormycosis masquerading as endobronchial tumour in an immunocompetent pregnant young lady

Ng KL, Huan NC, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2021 Feb;9(2):e00704.
PMID: 33364028 DOI: 10.1002/rcr2.704

Pulmonary mucormycosis is a rare but rapidly progressing and life-threatening fungal infection, usually affecting immunocompromised patients. We report a case of a previously healthy young lady who presented with prolonged cough, weight loss, and haemoptysis. Imaging showed left hilar mass with infiltration into the left main bronchus and concurrent mediastinal lymphadenopathy. Flexible bronchoscopy revealed an endobronchial mass occluding the left main bronchus. Tumour debulking was performed using rigid bronchoscopy with cryoprobe and snares. Histopathological examination revealed inflamed tissue with fungal organism. Fungal polymerase chain reaction (PCR) confirmed Rhizopus microsporus. She was treated with two weeks of intravenous amphotericin-B with complete clinical and radiological resolution.
Fulltext Conservative management of airway tear as a complication of silicone endobronchial stenting in bronchomalacia secondary to endobronchial tuberculosis

Huan NC, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2020 Dec;8(9):e00684.
PMID: 33194207 DOI: 10.1002/rcr2.684

Tracheobronchial stenosis due to tuberculosis (TSTB) is a potentially debilitating complication of endobronchial tuberculosis (EBTB). Endobronchial interventions including silicone stent insertion is an acceptable approach to improve quality of life among patients with TSTB. However, little is known about the optimal management strategy for patients with bronchomalacia secondary to EBTB (B-EBTB) and whether stent-related complication rates are higher among this group of patients. Herein, we report two patients with B-EBTB who unfortunately developed bronchial tear related to silicone endobronchial stenting. Both patients were successfully managed conservatively without the need for emergency open surgery. We hypothesize that endobronchial intervention might be more beneficial for patients with pure TSTB and might be riskier in cases of bronchomalacia with reduced airway thickness and loss of airway cartilaginous support. More future studies are needed to bridge the current gap in knowledge regarding the optimal management and role of endobronchial interventions among patients with B-EBTB.
Fulltext Topical mitomycin-C as an adjuvant to multimodal endoscopic treatment for tracheobronchial stenosis secondary to endobronchial tuberculosis

Huan NC, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2021 Mar;9(3):e00711.
PMID: 33532074 DOI: 10.1002/rcr2.711

Tracheobronchial stenosis secondary to endobronchial tuberculosis (TSTB) is a rare but debilitating complication of endobronchial tuberculosis (EBTB). Topical mitomycin-C (TMC) has been successfully utilized to restore airway patency and to prevent recurrence of TSTB, although little is known about its exact efficacy. Here, we report the biggest case series to date involving seven patients who received TMC as part of multimodality endoscopic treatment for TSTB with varying levels of success. All patients presented with dyspnoea during or after treatment completion for pulmonary tuberculosis (PTB). Four patients had short-segment concentric membranous TSTB while two patients had concurrent bronchomalacia. Another one patient had a thick fibrotic band adjacent to luminal opening. We hypothesize that TMC is more efficacious in short membranous stenosis without concurrent bronchomalacia and/or thick fibrotic bands. More studies are needed to bridge the current gaps in knowledge regarding the optimal role and benefits of TMC for TSTB patients.
Fulltext Bronchial thermoplasty for severe asthmatics: a real-world clinical study from Malaysia

Soo CI, Mak WW, Nasaruddin MZ, Ismail R, Ban AY, Abdul Rahaman JA

Singapore Med J, 2024 Feb 01;65(2):119-122.
PMID: 34617697 DOI: 10.11622/smedj.2021144

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