Case Presentation Competition, 5 Back to Basics

Serotonin syndrome associated with clozapine withdrawal and concurrent selective serotonin reuptake inhibitor (SSRI) use has previously been reported. A 56-year-old female with schizophrenia was admitted for pyrexia, rigidity, and altered mental state after her second dose of clozapine restart. She had discontinued her long-term clozapine 2 weeks prior. She developed ventilatory failure, reduced consciousness, eye deviation, and worsening rigidity, requiring ICU support. Examination showed a right upper motor neurone syndrome with absent ankle reflexes. She had raised inflammatory markers and creatine kinase. Serum neuropathy, encephalitis screen, and COVID PCR were negative. Respiratory investigations were unfruitful. MRI head and spine did not show brain or cord signal change to correlate to signs. Lumbar puncture showed a quiet CSF, negative culture, viral PCR, and encephalitis antibodies. EEG showed bihemispheric background slowing. Despite clinical improvement, repeat examination showed persistent signs. She was diagnosed with serotonin syndrome after developing a bilateral tremor. Treatment with cyproheptadine correlated with an improvement in her signs, cognitive state, and EEG. Serotonin syndrome can present with reversible neuromuscular signs. With clozapine withdrawal, it can require a prolonged time course of recovery in contrast with classical serotonin syndrome. Cyprohepta- dine can cause agranulocytosis and this delays clozapine restart.

Acute hypercapnic respiratory failure in patients with obesity hypoventilation syndrome during the COVID-19 pandemic: Four case reports.

Obesity hypoventilation syndrome (OHS) can cause acute hypercapnic respiratory failure (AHRF). The onset of AHRF in four patients with OHS during the coronavirus disease 2019 (COVID-19) pandemic is reported in this study. Two men (23 and 45 years old) and two women (both 77 years old) presented to our hospital with AHRF. In the two elderly women, a prolonged supine position due to falls seemed to be the cause of AHRF. Treatment was started with bilevel positive airway pressure for all patients. While one patient died, the condition of the other three improved; they were discharged with continuous positive airway pressure. AHRF due to OHS was rarely reported in the rural region of Japan. It is suggested that increased rates of obesity due to lifestyle changes during the COVID-19 pandemic may be responsible for an increase in the prevalence of OHS-associated AHRF.

Outcome of Long Term Ventilation (LTV) following remote initiation and monitoring in patients with Chronic Hypercapnic Respiratory Failure (CHRF) during the SARS-CoV-2 pandemic

Background: In the absence of LTV, CHRF leads to recurrent hospital admissions, poor quality of life and increased mortality. Anticipating a significant surge in SARS-CoV-2 our long term ventilation staff were redeployed to provide acute COVID service. NIV was considered as an aerosol generating procedure and due to lack of regular outpatient clinical activity, we implemented a remote LTV initiation and review service and have evaluated the clinical outcomes Method: Consecutive patients started on LTV over a 12 month period were included. Patient demographics, LTV indications, trial duration, remote review and clinical outcomes were evaluated Results: N=54, mean age;60+/-16, mean FEV1;45+/-24, mean BMI;39+/-18, males-54%. indications for LTV were OHS-56%, COPD-28%, NMD-7%, Chest wall disorders-6% and others (overlap syndromes and opioid induced)-3%. A third of patients needed supplemental oxygen therapy (2-4 lts/16-24 hours/day). The median (IQR) duration of LTV trial was 4.3 (1-5-4.5) months and mean (SD) NIV compliance was 5.5 (2.3) hours. Patients were regularly monitored remotely (via modem or telephone) due to clinical shielding advice and this prevented hospital admissions in 56% of patients. A significant improvement in pCO2 was noted (P -0.0009, mean pCO2 pre LTV: 9 +/- 2.85 v/s post LTV: 6.7 +/- 1.3, DELTA change 2.2 kpa, 95% CI: 1.2 -3.52). 9.3% had SARS-CoV-2 infection with all-cause mortality of 3.7% Conclusion(s): LTV can be initiated and monitored remotely & effectively. Adequate compliance and improvement of hypercapnia are key parameters of good outcome with LTV and remote monitoring may be cost effective.

Initial COVID-19 Severity and Long-COVID Manifestations: An Observational Analysis

OBJECTIVE: New-onset or persistent symptoms beyond after 4 weeks from COVID-19 are termed "long-COVID." Whether the initial severity of COVID-19 has a bearing on the clinicoradiological manifestations of long COVID is an area of interest. MATERIAL AND METHODS: We did an observational analysis of the long-COVID patients after categorizing them based on their course of COVID-19 illness into mild, moderate, and severe groups. The clinical and radiological profile was compared across these groups. RESULT(S): Out of 150 long-COVID patients recruited in the study, about 79% (118), 14% (22), and 7% (10) had a history of mild, moderate, and severe COVID-19, respectively. Fatigue (P = .001), breathlessness (P = .001), tachycardia (P = .002), tachypnea (P < .001), raised blood pressure (P < .001), crepitations (P = .04), hypoxia at rest (P < .001), significant desaturation in 6-minute walk test (P = .27), type 1 respiratory failure (P = .001), and type 2 respiratory failure (P = .001) were found to be significantly higher in the long-COVID patients with a history of severe COVID-19. These patients also had the highest prevalence of abnormal chest X-ray (60%) and honeycombing in computed tomography scan thorax (25%, P = .027). CONCLUSION(S): The course of long COVID bears a relationship with initial COVID-19 severity. Patients with severe COVID-19 are prone to develop more serious long-COVID manifestations.Copyright © Author(s).

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS VERSUS CALCIUM CHANNEL BLOCKERS IN ASSOCIATION WITH MORTALITY RATE IN COVID-19 HYPERTENSIVE PATIENTS: THE EFFECT OF AGE

Objective: To study the association of calcium channel blockers (CCBs), the renin-angiotensin-aldosterone system (RAAS) inhibitors or their combination as antihypertensive medications and the clinical outcome of COVID-19 infection. Design and method: This is a retrospective cohort study using de-identified data retrieved from clinical records of COVID-19 patients in two isolation centers. Medical history, demographic data, symptoms, complications and laboratory investigations were extracted from clinical records of 406 confirmed COVID-19 hospitalized patients between Feb 2020 and July 2021. Hypertension and antihypertensive treatments were confirmed by medical history and clinical records. Continuous variables were presented as means ± standard deviation (SD) while categorical variables were presented as percent proportions. Logistic regression was used to assess the impact of antihypertensive drugs (RAAS inhibitors, CCBs, combination of RAAS inhibitors and CCBs and those not receiving medication) on the prognosis of COVID-19 patients and to explore the risk factors associated with mortality. Result: Out of 406 hospitalized COVID-19 patients, 242 (59.6%) had a history of hypertension. Hypertensive patients under the age of 65 years and receiving RAAS inhibitors or the combination of both RAAS inhibitors and CCBs were at higher risk of mortality than those on CCBs only (odds ratio [OR]: 4.45, 95% confidence interval [CI]: 1.56-12.56, P = 0.005 and OR:3.57, CI: 1.03-12.36, P = 0.045 respectively). Antihypertensive medications did not seem to influence mortality rates among hypertensive patients above 65 years. Routine laboratory investigations were not significantly different between the subgroups receiving different antihypertensive medications regardless of age. Cough was the only symptom associated with mortality among patients under 65 years (OR:2.34, CI:1.24-4.41, P = 0.009). Type II respiratory failure was significantly associated with death among hypertensives under 65 years (OR:5.43, CI:1.08-28.07, P = 0.044) whereas acute kidney injury and septic shocks are the common complications related to death among hypertensives above 65 years (OR:3.59, CI:1.54-8.36, P = 0.003 and OR:7.87, CI: 1.68-36.78, P = 0.009 respectively). Conclusion: Administration of CCBs may improve the outcome of COVID-19 hypertensive patients under 65 years of age. Antihypertensive treatment does not seem to influence the prognosis of COVID-19 patients above 65 years. Such results may affect management strategy of COVID-19 hypertensive patients. Type-II respiratory failure among patients under 65 years of age, acute kidney injury and septic shock among those above 65 years are the most serious complications that can lead to death regardless of blood pressure.

Coughing up a lung? Expectoration of obstructive fibrinous tracheal pseudomembrane

Case Report: Most common causes of shortness of breath are asthma, COPD, CHF, pulmonary embolism, diffuse lung parenchymal diseases and obesity hypoventilation syndrome. Rare conditions can be bronchiectasis, constrictive pericarditis, kyphoscoliosis, tracheomalacia, cardiomyopathies and so on. We present a rare case of tracheal stenosis presenting with repeated hospital admissions followed by intubations and resolution after spontaneous expectoration. A 52-year-old female with a history of end stage renal disease on hemodialysis, resistant hypertension, and COVID pneumonia on supplemental oxygen, presented with dyspnea associated with yellowish productive sputum for one day. She was admitted one week prior due to the same complaint associated with encephalopathy due to hypercapnia, required endotracheal intubation, got extubated four days later, was provisionally diagnosed with asthma and volume overload, and discharged home. During the admission of interest, the patient's examwas normal except severe hypertension with BP of 192/101, bilateral crackles and rhonchi. Arterial blood gasses (ABGs) again showed hypercapnia. CT thorax showed evidence of left lower lobe pulmonary infiltrate and ground-glass opacities. Due to repeated admissions for hypercapnic respiratory failure, suspicion for persistent anatomic or pathologic abnormality was high. Reexamination of CT thorax suggested subglottic stenosis and she underwent fiberoptic laryngoscopy which revealed grade 3 subglottic stenosis. On day three, she became hypoxic and unresponsive, ABGs revealed PCO2 of 150, and got intubated again. Soon after intubation, the patient had spontaneous expectoration of a large piece of firm, fleshy, blood-tinged, thick, luminal tissue. On the histologic examination, the material was found to be a plug of fibrin with small to moderate numbers of inflammatory cells embedded in the matrix. Follow-up CT neck and chest revealed resolution of previously visualized tracheal stenosis. She underwent repeat direct laryngoscopy and flexible bronchoscopy which did not show any tracheal stenosis. The patient remained hemodynamically stable and was discharged home. Tracheal stenosis is challenging to diagnose. Examples of tracheal stenosis due to pseudomembrane formation are rare in medical literature, and the expectoration of fibrin material after intubation in a person with this condition is even rarer. A similar case has been described before with an identical situation of coughing up soft tissue and comparable histopathology report. Our case highlights the importance of critical analysis for broad differentials, adding up pieces of the puzzle to explain the missing link. This patient came with recurrent episodes of dyspnea that were misdiagnosed as volume overload, pneumonia, and asthma exacerbations. CT chest findings of possible subglottic stenosis were the missing link in this case which steered further work-up and led to the final diagnosis. Copyright © 2023 Southern Society for Clinical Investigation.

CAUSES OF DEATH AMONG MEDICAL ICU (MICU) PATIENTS WITH PNEUMONIA DUE TO COVID-19 IN A SAFETY NET HOSPITAL

SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: COVID-19 infection has a wide spectrum of clinical presentation ranging from asymptomatic carriers to severe critical illness associated with high morbidity and mortality. Although severe COVID-19 disease is associated primarily with pulmonary dysfunction and hypoxemia, many patients with lung disease can be supported by invasive mechanical ventilation allowing for other causes or complications to be the primary factor leading to death. The contribution of pulmonary dysfunction to the primary cause of death is not well-described. METHODS: We performed a retrospective cohort study of adult patients (age ≥ 18 years) admitted to the MICU at Los Angeles County + University of Southern California (LAC + USC) hospital from April 2020 to December 2020 with a primary diagnosis of COVID-19 pneumonia associated with documented in-hospital death. Data including baseline patient characteristics, primary cause of death and/or circumstance prior to withdrawal of care, and disease course were collected. The primary organ system responsible for death was defined as the organ dysfunction that most directly resulted in the patient’s death or impacted the decision for withdrawal of life support with details adapted from Ketcham, et al (Crit Care, 2020). RESULTS: We identified 86 patients who were admitted to the ICU that met inclusion criteria for review, of which 75% were male and 93% were Latino/Hispanic. Mean age on admission was 64 years. Of the 86 patients, 47 (54%) died from a primary pulmonary cause, 28 (32%) died from sepsis, 5 (6%) died from neurologic causes, and 4 (5%) died from either renal or hemorrhagic causes. Of the 47 patients who died primarily from pulmonary causes, 34 (72%) died from hypoxemic respiratory failure, 8 (17%) died from hypercapnic respiratory failure, and 5 (11%) died from combined respiratory failure. Of the 28 patients who died primarily from sepsis, 13 (46%) died from pneumonia, 7 (25%) died from fungemia, and 3 (11%) died from bacteremia with an identified source. Overall, 58 (67%) patients had multi-organ failure at time of death. Mean time from symptom onset to death was 27 days. Of the 69 patients who were intubated, mean times from admission to intubation and intubation to death was 4 and 19 days respectively. Only 1 patient who died underwent tracheostomy. CONCLUSIONS: We found that pulmonary dysfunction was the primary cause of death in the first year of the pandemic in our patient population at our single center MICU. Future studies are needed to further evaluate the primary cause of death in COVID-19 infection throughout the pandemic as medical management evolved and virus variant changed with time. CLINICAL IMPLICATIONS: Our study confirmed that a majority of patients with severe COVID-19 pneumonia died from hypoxemic respiratory failure. Further studies regarding COVID-19 interventions should focus on therapies to improve oxygenation. DISCLOSURES: No relevant relationships by Christopher Do No relevant relationships by Luis Huerta No relevant relationships by Janice Liebler

GAINING CONSENSUS ON EXPERT RULE STATEMENTS FOR A DIGITAL TWIN PATIENT MODEL IN THE ICU USING A DELPHI METHOD

SESSION TITLE: Optimizing Resources in the ICU SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: The COVID-19 pandemic has exposed worldwide heterogeneity in the application of fundamental critical care principles and best practices. New methods and strategies to facilitate timely and accurate interventions are needed. If built on a robust foundation of physiologic principles, a virtual critically ill patient (aka digital twin) could better inform decision making in critical care. When used in clinical practice, a digital twin may allow bedside providers to preview how organ systems interact to cause a clinical effect, providing the opportunity to test the effects of various interventions virtually, without exposing an actual patient to potential harm. Building on our previous work with a digital twin model of critically ill patients with sepsis, this current project focuses specifically on the respiratory system. METHODS: We assembled a modified Delphi panel of 36 international critical care experts. We modeled elements of respiratory system pathophysiology using directed acyclic graphs (DAG) and derived several statements describing associated ICU clinical processes. Panelists participated in three Delphi rounds to gauge agreement on 71 final statements using a 6-point Likert scale. Agreement was defined as >80% selection of a 5 (“agree”) or 6 (“strongly agree”). RESULTS: The first Delphi round included statements of pulmonary physiology affecting critically ill patients, eg pulmonary edema, hypoxemic and hypercapnic respiratory failure, shock, acute respiratory distress syndrome (ARDS), airway obstruction, restrictive lung disease, and ventilation-perfusion mismatch. Agreement was achieved on 60 (84.5%) of expert statements after completion of two rounds. After partial completion of the third round, agreement increased to 62 (87%). Statements with the most agreement included the physiology and management of airway obstruction decreasing alveolar ventilation and the effects of alveolar infiltrates on ventilation-perfusion matching. Lowest agreement was noted for the statements describing the interaction between shock and hypoxemic respiratory failure due to increased oxygen consumption and ARDS increasing dead space. CONCLUSIONS: An international cohort of critical care experts reached 87% agreement on our rule statements for respiratory system pathophysiology. The Delphi approach appears to be an effective way to refine content for our digital twin model. CLINICAL IMPLICATIONS: Expert consensus can be used to strengthen the respiratory physiology statements used to direct the ICU digital twin patient model. With a digital twin based on refined respiratory physiology statements, bedside providers may preview how organ systems interact to cause a clinical effect without exposing an actual patient to various interventions. DISCLOSURES: No relevant relationships by Ognjen Gajic, value=Royalty Removed 06/06/2022 by Ognjen Gajic No relevant relationships by Amos Lal No relevant relationships by John Litell No relevant relationships by Amy Montgomery

Parameters that affect the outcome in ICU patients with critical COVID -19 infection

Introduction: COVID -19 pandemic continues to affect millions worldwide, while the critical form of the disease requires ICU hospitalization to manage not only respiratory failure but multiple organ dysfunctions as well. Objectives: Our retrospective observational study aimed to test the hypothesis that there is a difference in mean values of indexes pointing to organ dysfunction on ICU admission day, like BUN over Creatinine ratio, BUN over Albumin ratio, and PaCO2 over HCO3 ratio among patients with confirmed critical COVID -19 infection who died and patients who survived ICU. Methods: During late 2020 to 2021, 69 patients indicated with the diagnosis of critical COVID -19 disease admitted to ICU. The patients were separated into two groups. Group A involved all patients who survived ICU and group B all patients who died in ICU. We looked for statistically significant differences between the medians values of two groups according to BUN/Cr, BUN/Alb, PaCO2/HCO3 ratios on the ICU admission day, performing unpaired t-test or Mann-Whitney Test according to equal S.D.s assumption. Results: (Table) Conclusions: According to our data, there was a strong statistically significant difference detected between the two groups according to BUN/Alb and PaCO2/HCO3, while the BUN/Cr ratio had no statistically significant difference. Our data suggest that prerenal disorder took place early and was already present on ICU admission day, although not statistically greater in group B. However, a renal disorder associated with albumin levels was greater in group B, and acute type II respiratory failure was by far greater in patients that died in the ICU, pointing that oxygenation disorder was not the only impact of COVID -19 infection on the ICU admission day.

Retrospective audit of ED attendances in intensive care patients to prognostic outcome

Introduction: The aim of the audit was to assess the frequency of Emergency Department (ED) attendances before and after Intensive care and correlate this with functional decline and worsening comorbidities. Though the Covid 19 pandemic has highlighted this more starkly1 the implications of prolonged ICU care and increased long term care needs is well established.2 Objectives: A well-structured, comprehensive, multidisciplinary rehabilitation program during and after discharge from the hospital could improve outcomes and prevent further hospital/ED visits. Method: Data was collected using the ITU admission data base for all > 72 hour ITU patient stays over a two year period of 2017-2018 and 2018-2019 in a district general hospital in the UK. Each individual patient's number of same hospital ED attendances for twelve months before and after their ITU admission were reviewed and the causes for them assessed, in addition survival data over a two year period was also reviewed. Results: During 2017-2018 and 2018-2019 a total of 414 and 425 patients were admitted respectively to ITU for more than 72 hours (median= 133.5 hours). Of the total 839 ITU admissions 700 (83.4%) survived ICU stay. 165 (23.6%) of the 700 patients died in subsequent 2 years of ITU discharge. The two year survival rate was 65%. The most common ITU admissions reason was postoperative monitoring (20%) followed by Type 1 respiratory failure (18%) and Type 2 respiratory failure (15%). The median ED attendance was 0 (Range 0 to 29, mean 0.985, S.D 3.985) in the 17-18 and 0 (Range 0 to 24, mean 1.153, SD 2.154) in the 18-19 cohort in the 12 months prior to ITU admission while the median ED attendance was 0 (Range 0 to 15, mean 0.980, S.D 4.4) in the 17-18 and 0 (Range 0 to 15, mean 1.19, SD 2.0) in the 18-19 cohort in the 12 months following the ITU admission. 98% for 17-18 and 72% for 18-19 of ED reattendances following prolonged ITU stay were due to reasons similar to ITU care. Of the 445 patients with no prior ED attendance in 1 year, 168 or 38% (range 1 to 14) had at least one ED attendance in the 12 months following ITU discharge. The remaining 394 patients with at least one ED attendance prior to ICU, 185 or 47% (1 to 15 Range) had ED attendance 12 months following their ITU discharge. Conclusion: The results show that ITU admitted patients consume significant health resources before and after their ITU stay. Patients with no prior ED attendances before ITU admission also reattended in substantial numbers. Most of these attendances were related to their initial reason for ITU admission. A comprehensive rehabilitation program both in hospital and following discharge could improve patients' outcomes, reduce stress on emergency services and improve patient experience. A rehab service was implemented. The need for rehab program for Covid 19 patients during the pandemic has grown immense because of evolving evidence of Long Covid.3.

Real-World Use of Extracorporeal CO2 Removal (ECCO2R) to Correct Respiratory Acidosis: Analysis of the Hemolung Registry

Hypercapnia and respiratory acidosis lead to increased morbidity and mortality in critically ill patients. Extracorporeal CO2 removal (ECCO2R) can rapidly correct pH and PaCO2 as a treatment for refractory, hypercapnic respiratory failure. Current clinical evidence for the benefits of ECCO2R is primarily limited to case series and single-center studies. The Hemolung (ALung Technologies, Inc., Pittsburgh, PA) is the only FDA cleared ECCO2R system and has been utilized to treat greater than 1,000 patients world-wide. The purpose of this study was to evaluate real-world evidence of the Hemolung ECCO2R system for the treatment of hypercapnic respiratory failure across a range of primary diagnoses. Methods: The Hemolung Registry was queried for patients with a baseline, pre-Hemolung pH < 7.35. Patients receiving either noninvasive or invasive ventilation were included in the analysis. Physiological benefits of Hemolung therapy were evaluated using a mixed model for repeated measures based on changes in pH and PaCO2 after 4-6 hrs and 16-35 hrs of Hemolung therapy compared to the baseline value. The model was used to calculate two-sided 95% confidence intervals and associated nominal p-values. Additional markers of clinical improvement included avoidance of intubation, survival to decannulation, and Hemolung CO2 removal rate and duration of use. Adverse events were also analyzed based on patient harm. Results: 176 Hemolung patients were included in the analysis. Multiple primary diagnoses were represented: 31% ARDS, 22% COPD exacerbation, 32% COVID-19, and 15% Other. Median CO2 removal by the Hemolung during the first day of therapy was 88 mL/min and resulted in a concomitant correction of pH from a median of 7.20 to 7.35 (p<0.001) and median PaCO2 correction of 81.7 to 57.0 mmHg (p<0.001). Correction of respiratory acidosis was independent of primary diagnosis, age, and BMI. 69% (112/162) of patients survived to de-cannulation. 86% (19/22) of patients failing NIV avoided intubation. There were no unanticipated complications, and the majority of adverse events did not require medical intervention or discontinuation of Hemolung therapy. 3 deaths associated with Hemolung therapy occurred. Conclusion: These data represent the largest reported analysis of ECCO2R therapy to treat a diverse population of hypercapnic respiratory failure patients. The results demonstrate significant correction of pH and PaCO2 within the first day of Hemolung therapy without significant adverse events. Data from forthcoming RCTs will shed further light on whether these physiologic benefits translate to improved outcomes compared to current standard of care.

Real-World Evidence of ECCO2R to Correct Respiratory Acidosis: Analysis of the Hemolung Registry

Rationale: Hypercapnia and respiratory acidosis lead to increased morbidity and mortality in critically ill patients. Extracorporeal CO2 removal (ECCO2R) can rapidly correct pH and PaCO2 as a treatment for refractory, hypercapnic respiratory failure. Current clinical evidence for the benefits of ECCO2R is primarily limited to case series and single-center studies. The Hemolung (ALung Technologies) is the only FDA cleared ECCO2R system and has been utilized to treat greater than 1,000 patients world-wide. The purpose of this study was to evaluate real-world evidence of the Hemolung ECCO2R system for the treatment of hypercapnic respiratory failure across a range of primary diagnoses. Methods: The Hemolung Registry was queried for patients with a baseline, pre- Hemolung pH < 7.35. Patients receiving either noninvasive or invasive ventilation were included in the analysis. Physiological benefits of Hemolung therapy were evaluated using a mixed model for repeated measures based on changes in pH and PaCO2 after 4-6 hrs and 16-35 hrs of Hemolung therapy compared to the baseline value. The model was used to calculate two-sided 95% confidence intervals and associated nominal p-values. Additional markers of clinical improvement included avoidance of intubation, survival to decannulation, and Hemolung CO2 removal rate and duration. Adverse events were also analyzed based on patient harm. Results:176 Hemolung patients were included in the analysis. Multiple primary diagnoses were represented: 31% ARDS, 22% COPD exacerbation, 32% COVID-19, and 15% Other. Median duration of Hemolung therapy was 6.0 days. Median CO2 removal by the Hemolung during the first day of therapy was 88 mL/min and resulted in a concomitant correction of pH from a median of 7.20 to 7.35 (p<0.001) and median PaCO2 correction of 81.7 to 57.0 mmHg (p<0.001). Correction of respiratory acidosis was independent of primary diagnosis, age, and BMI. 69% (112/162) of patients survived to decannulation. 86% (19/22) of patients failing NIV avoided intubation. There were no unanticipated complications, and the majority of adverse events did not require medical intervention or discontinuation of Hemolung therapy. 3 deaths associated with Hemolung therapy occurred. Conclusions: These data represent the largest reported analysis of ECCO2R therapy to treat a diverse population of hypercapnic respiratory failure patients. The results demonstrate significant correction of pH and PaCO2 within the first day of Hemolung therapy without significant adverse events. Data from forthcoming RCTs will shed further light on whether these physiologic benefits translate to improved outcomes compared to current standard of care.

Severe Tracheal Stenosis in a Patient with History of Prolonged Intubation

Post-intubation tracheal stenosis (PiTS) is a complication that occurs in 10-22% of patients after prolonged intubation or tracheostomy. Predisposing factors include localized infection, soft tissue trauma, granulation at the site of stoma, hypotension, tracheal cartilage damage, and metabolic disorders. Despite advances in the design of endotracheal tubes and cuffs, PiTS continues to remain an undesired consequence that warrants increased attention, especially in the COVID pandemic, which has led to increased number of tracheostomies and intubations. Consequently, prompt diagnosis and management is imperative to improve patient survival and quality of life. Herein, we present a 52-year-old male with history of tracheostomy in the setting of prolonged intubation from intraparenchymal hemorrhage with subsequent decannulation who was admitted for the management of pulmonary embolism. His course was complicated by encephalopathy and acute hypercapnic respiratory failure requiring intubation. In the intensive care unit, the patient was extubated after improvement in his respiratory and mental status, however developed shortness of breath and the feeling of impending doom a few hours after extubation. Chest radiograph was obtained and suggested tracheal stenosis (Image-1A). Given this finding, follow-up urgent chest computed tomography demonstrated severe lateral collapse of the subglottic space with critical tracheal stenosis (Image-1B). There was >90% cross sectional area reduction at the site of greatest stenosis (Image-1C). The measured area at the site of greatest stenosis was noted at 0.32 cm2 (average tracheal area is 2.8-3.4 cm2). His tracheal stenosis was suspected to be secondary to his history of tracheostomy. Given these findings, patient was reintubated for airway protection and urgently underwent rigid bronchoscopy. Initially, argon plasma coagulation was used in between stenotic areas, however there was minimal improvement in the airway, requiring a silicone 18 x 14 x 14 cm Y-stent to be placed. Since stent placement, patient has required frequent bronchoscopies to assist with mucus and secretion clearing. The remainder of his hospital course was benign. PiTS is an infrequent yet important complication that clinicians must consider in individuals with a history of prolonged intubation who have sudden difficulty breathing postextubation. Prompt recognition is required to manage these patients effectively. Factors considered in the management include location, length, and the severity of the stenosis. Therefore, if 1) critical stenosis is suspected, 2) the facility is capable of resection and reconstruction, and 3) the patient has minimal comorbidities, surgery should be considered. Otherwise, bronchoscopy with stent placement can be performed.

Atypical Variant of Guillain Barre Syndrome in a Patient with COVID-19.

OBJECTIVE: A rare variant Miller Fisher Syndrome overlap with Guillain Barre Syndrome is described in an adult patient with SARS-COV-2 infection. CASE PRESENTATION: The clinical course of a 45-year-old immunosuppressed man is summarized as a patient who developed ataxia, ophthalmoplegia, and areflexia after upper respiratory infection symptoms began. A nasopharyngeal swab was positive for COVID-19 polymerase chain reaction. He progressed to acute hypoxemic and hypercapnic respiratory failure requiring intubation and rapidly developed tetraparesis. Magnetic resonance imaging of the spine was consistent with Guillain Barre Syndrome. However, the clinical symptoms, along with positive anti-GQ1B antibodies, were consistent with Miller Fisher Syndrome and Guillain Barre Syndrome overlap. The patient required tracheostomy and had limited improvement in his significant neurological symptoms after several months. CONCLUSIONS: The case demonstrates the severe neurological implications, prolonged recovery and implications in the concomitant respiratory failure of COVID-19 patients with neurological symptoms on the spectrum of disorders of Guillain Barre Syndrome.