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Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.
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INTRODUCTION: The occurrence of pneumomediastinum (PM) and/or pneumothorax (PTX) in patients with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated. METHODS: This was a prospective observational study conducted in patients admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital in Madrid (Spain) between December 14, 2020 and September 28, 2021. All patients had a diagnosis of severe SARS-CoV-2 pneumonia and required noninvasive respiratory support (NIRS): high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The incidences of PM and/or PTX, overall and by NIRS, and their impact on the probabilities of invasive mechanical ventilation (IMV) and death were studied. RESULTS: A total of 1306 patients were included. 4.3% (56/1306) developed PM/PTX, 3.8% (50/1306) PM, 1.6% (21/1306) PTX, and 1.1% (15/1306) PM + PTX. 16.1% (9/56) of patients with PM/PTX had HFNC alone, while 83.9% (47/56) had HFNC + CPAP/BiPAP. In comparison, 41.7% (521/1250) of patients without PM and PTX had HFNC alone (odds ratio [OR] 0.27; 95% confidence interval [95% CI] 0.13-0.55; p < .001), while 58.3% (729/1250) had HFNC + CPAP/BiPAP (OR 3.73; 95% CI 1.81-7.68; p < .001). The probability of needing IMV among patients with PM/PTX was 67.9% (36/53) (OR 7.46; 95% CI 4.12-13.50; p < .001), while it was 22.1% (262/1185) among patients without PM and PTX. Mortality among patients with PM/PTX was 33.9% (19/56) (OR 4.39; 95% CI 2.45-7.85; p < .001), while it was 10.5% (131/1250) among patients without PM and PTX. CONCLUSIONS: In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia requiring NIRS, incidences of PM/PTX, PM, PTX, and PM + PTX were observed to be 4.3%, 3.8%, 1.6%, and 1.1%, respectively. Most patients with PM/PTX had HFNC + CPAP/BiPAP as the NIRS device, much more frequently than patients without PM and PTX. The probabilities of IMV and death among patients with PM/PTX were 64.3% and 33.9%, respectively, higher than those observed in patients without PM and PTX, which were 21.0% and 10.5%, respectively.
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Extracorporeal Membrane Oxygenation is a resource intensive therapy;heavily reliant upon specialized equipment, unique disposables, and skilled staff. The Covid-19 pandemic and following events exposed flaws in multiple phases of the care delivery system. The combination of high patient census, acuity, manufacturing delays, and supply chain disruptions led to our center's reassessment of the way in which limited resources are utilized. As a combined pediatric and adult center, we possess the ability to share resources amongst all patient populations. Currently, the majority of our equipment and disposables support a heavier use of Centrimag. We adjusted our general weight guidelines in order to best serve the most patients. (<8kg Sorin Rollerhead, 8-20kg Sorin Revolution, >20kg Centrimag.) Presently, a major challenge is the cessation of production of the -inch Better Bladder. The ECMO Coordinator team collaborated with key physician stakeholders. It was decided that the fluid reservoir and air trap benefits of a bladder outweighed the risks of running without one on our Sorin Rollerhead circuit. We designed a circuit with a 3/8 Bigger Better Bladder. Recognizing the increased risk of clotting with the 3/8 segment, we added a post-oxygenator shunt. This allows for adequate blood flow to maintain circuit integrity, while limiting the amount of flow to the patient. The nationwide nursing shortage is well-known. Though our multidisciplinary ECMO Specialist Team supports nursing and respiratory therapy, the nursing shortage still impacts our staffing models, resulting in the inability to safely staff bedside nurses and ECMO specialists. At times of high census, ECMO patients are cohorted into one geographical location. This allows for a temporary 2:1 staffing model for Centrimag patients. Our goal remains to staff pediatric cases as a 1:1 ECMO Specialist assignment. The ability to obtain this is assessed shift to shift;factoring patient stability, experience of the ECMO specialist, and unit staffing. The collaboration with ICU Nurse Managers, Hospital Supervisors and Central Staffing Office is imperative to the success of staffing model alterations. Our ECMO department has increased its FTEs, implementing a core team to be preassigned to two ECMO beds. The objective is to alleviate the burden on ICU staffing, limiting the number of nurses pulled from staffing grids. In uncertain times, flexibility is vital. It is important to remain vigilant and proactive. Our ECMO program feels that continuous assessment of supplies, equipment, and open communication has been the key to successfully serving our patients.
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Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.
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Ferula asafoetida is an endemic species in Iran and is rich in oleo-gum resin with high economic value in the world. One important application of F. assafoetida is its traditional use for the management of respiratory ailments. The aim of this review was to collect papers dealing with F. asafoetida oleo-gum resin in respiratory tract's diseases in modern medicine. For preparing the manuscript the scientific databases (Google scholar, PubMed, Springer, Science Direct, Magiran), books, thesis, etc. were searched using the keywords of "Ferula asafoetida", "Ferula scorodesma", "Scorodesma foetida", "Northex asafoetida" plus "respiratory tract", "respiratory disorder" "infection", "cough", "trachea", "traditional medicine" up to Feb 2022 and the collected data were sum-marized, analyzed, and discussed. The results of the investigation confirmed the traditional belief on the efficacy of Ferula asafoetida in the treatment of respiratory viral infection (Coronavirus, influ-enza), cigarette smoking, asthma, cough and cancer, but most studies were limited to in vitro. There was only one registered randomized, blinded, placebo controlled clinical trial for 300 mg F. asafoet-ida aqueous extract capsules (three times a day for 14 days) on 40 patients with COVID-19 without any published results. Although, the studies implied the efficacy of F. asafoetida in the treatment of respiratory treatments, but design large clinical studies for evaluating its efficacy and safety is essential in future investigations.Copyright © 2023 Bentham Science Publishers.
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The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.Copyright © 2022
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Aim: To determine the effect of the early combination of high flow nasal cannula (HFNC) plus continuous positive airway pressure (CPAP) regarding endotracheal intubation (ETI) and 30-day mortality in patients with SARS-CoV-2 pneumonia. Method(s): Observational study of patients admitted to the intermediate respiratory care unit (IRCU) who received HFNC+CPAP. Two groups were formed according to the time of starting the combined therapy: Early HFNC+CPAP (first 24 h - EHC) and Late HFNC+CPAP (after 24 h - LHC). A multivariate analysis was performed to establish the strength of the association with ETI and 30-day mortality. Result(s): 780 patients were included (502 male, mean age 56.5 +/- 12.9 years). Table 1 shows the baseline characteristics. 273 patients were subjected to ETI, 32.9% in the EHC group vs 38.9% in the LHC group (p 0.05). 30day mortality was 8.2% in the EHC vs 15.5% LHC (p 0.02). Table 2 shows the multivariate analysis. Conclusion(s): The combination of HFNC+CPAP, especially in the first 24 hours after IRCU admission, is a useful tool in the management of SARS-CoV-2 pneumonia.
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Although protection of vaccines against COVID-19 has been reported, very little is known about the clinical characteristics of hospitalized vaccinated patients. Method(s): This single-center cohort study of 1888 COVID-19 patients hospitalized at the "Enfermera Isabel Zendal" Emergencies Hospital, Madrid (Spain) was performed between July and September, 2021. It compared the results of 1327 unvaccinated patients to 209 fully vaccinated and 352 partially vaccinated. Vaccines administered were: BNT162b2, ChAdOx1 nCoV-19, mRNA-1273, Ad26.COV2.S. Finding(s): Hospitalized patients' median age was 41 years (IQR 33.0-50.0) for the unvaccinated and 61.0 years (IQR 53.0-67.0) for the fully vaccinated ones. The main comorbidities were obesity, hypertension and diabetes mellitus. The fully vaccinated patients obtained higher C-reactive protein values (median 48.9 mg/l [IQR 21.7-102.9]) and significantly lower for ferritin (median 367.0 ng/ml [IQR 182.0-731.0]) and lactate dehydrogenase (median 269.0 units/l [IQR 218.5-330.5]) values. 266 unvaccinated patients required noninvasive respiratory care, as did 51 partially vaccinated and 30 fully vaccinated patients;78 of the unvaccinated patients also needed invasive respiratory care, as did 16 partially vaccinated and 11 fully vaccinated patients. The fully vaccinated patients were 84% less likely to be admitted to hospital, and protection for those aged <50 years. Interpretation(s): Once hospitalized, the vaccinated patients displayed more protection against requiring respiratory care than the unvaccinated ones, despite being older and having more comorbidities. No differences appeared for the four studied vaccine types.
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OBJECTIVES: This study investigated the efficacy of flipped approach on the nurses' knowledge and motivation regarding critical respiratory care during the COVID-19 pandemic. RESULTS: This pretest-posttest quasi-experimental study was performed in a hospital affiliated with Shiraz University of Medical Sciences during March-December 2021. One hundred and twenty eligible nurses selected by convenience sampling underwent a seven-day flipped approach respiratory intensive care training. The nurses' motivation and knowledge were evaluated using the Students' Motivation Towards Science Learning (SMTSL) and a 20-researcher-made four-option questionnaire before and two weeks after the intervention, for knowledge assessment respectively. The nurses' knowledge and learning motivation were significantly higher after the intervention (P < 0.001). The flipped approach can improve learning motivation and nurses' knowledge of critical respiratory care.
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COVID-19 , Curriculum , Humans , Clinical Competence , Pandemics , Critical Care , TeachingABSTRACT
Rationale: Low-grade inflammation is a risk factor for adverse cardiovascular events including death from cardiovascular disease. Cardiovascular events are one of the most common manifestations of post covid syndrome, impacting the mortality in the post covid period. Methods: 260 post covid patients age 48-66 years were examined. All patients underwent rehabilitation in a Crimean sanitorium, that included climatologic therapy on the southern coast of Crimea;dietary therapy;pharmacologic therapy, and if necessary, breathing exercises using a variety of methods of respiratory therapy. The patients were examined for C-reactive protein (CRP) level in peripheral blood before and after the sanatorium rehabilitation. Results: The level of CRP of the patients who underwent rehabilitation did not differ significantly (p>0.05) from the initial values obtained on the day of admission to the rehabilitation center. At admission and upon discharge the CRP values corresponded to the lower limit of the levels characteristic of low-grade inflammation ranging from 3 mg/l to 10 mg/l). Conclusions: The currently available methods of physical rehabilitation of post covid patients as implemented in a Crimean sanitorium did not provide a reduction of the level of systemic inflammation as assessed by CRP determination. New less traditional approaches may be needed to reduce inflammation in post covid syndrome patients who are at risk for cardiovascular adverse consequences.
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An introduction is presented in which the author discusses articles within the issue on topics including environmental contamination by SARS-CoV-2 from COVID-19 19 subjects receiving noninvasive ventilation, SARS-CoV-2 aerosols during noninvasive respiratory support of COVID-19 patients, and response of positive airway pressure devices during treatment of sleep-disordered breathing.
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‘Advanced Respiratory Practice/Care' (ARP/C) has been offered at the University of Bradford since the summer 2020. Initially developed in response to one district general hospital's quest for respiratory staff education during COVID-19, student numbers of ARP/C have grown steadily. Thirty-five students from across the healthcare professions in West Yorkshire undertook the module in the spring of 2022. ARP/C was designed to promote multi-disciplinary peer learning through simulated practice scenarios. This paper discusses students' evaluations of ARP/C and how the module has been designed to embrace multi-disciplinary team learning. ARC/P students were divided into two groups based on critical care experience. This division aimed to tailor taught content and improve students' experiences in simulated practice learning. However this divide was resource-intensive and some students felt the differential teaching was disadvantaging. Simulated practice followed morning sessions of overarching theory. Simulated practice scenarios encouraged students' multi-disciplinary team problem-solving in supportive environments. Students particularly reported powerful learning in relation to human factors. Many students valued simulated practice learning, but some felt it lacked authenticity and personal fears debarred their positive experience. For ARP/C, in spring 2023, there has been investment in additional high-fidelity equipment and students will not be sub-divided for theoretical teaching.
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An introduction is presented in which the author discusses articles within the issue on topics including environmental contamination by SARS-CoV-2 from COVID-19 19 subjects receiving noninvasive ventilation, SARS-CoV-2 aerosols during noninvasive respiratory support of COVID-19 patients, and response of positive airway pressure devices during treatment of sleep-disordered breathing.
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The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge. Copyright © 2022
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Resumen Las Unidades de Cuidados Respiratorios Intermedios (UCRI) son áreas de monitorización y atención especializada de pacientes con insuficiencia respiratoria aguda o crónica-agudizada, cuya gravedad no precisa de ingreso en una Unidad de Cuidados Intensivos, pero que por su complejidad tampoco pueden ser tratados en planta de hospitalización convencional. Si bien la pandemia por COVID-19 ha demostrado su utilidad en el manejo del paciente respiratorio crítico, la trayectoria histórica de las UCRI viene de muchos años atrás, en la que se ha demostrado su coste-efectividad con creces. El presente documento presenta una serie de preguntas y respuestas sobre la historia de las UCRI, además de los criterios de admisión, infraestructura, recursos humanos y técnicos, y los tipos de Unidades existentes. En el seno del Año UCRI 2021-2022 designado por la Sociedad Española de Neumología y Cirugía Torácica, es oportuna toda divulgación científica vinculada al conocimiento a profundidad de estas Unidades, donde confluyen la multidisciplinariedad y el trabajo de profesionales relacionados con el cuidado del paciente respiratorio crítico. The Intermediate Respiratory Care Units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an Intensive Care Unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI Year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these Units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.
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SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: While rarely reported, there has been an increasing incidence of tracheobronchial mucormycosis in patients infected with COVID-19, especially when associated with uncontrolled diabetes mellitus. We describe a complex case of central airway obstruction due to mucormycosis that was managed with a custom 3D printed silicone Y-stent. CASE PRESENTATION: A 54-year-old woman with diabetes, prior COVID-19 infection, presented with dyspnea and cough. She underwent a CT chest which showed left lower lobe atelectasis and left main stem bronchus (LMSB) obstruction. Bronchoscopy showed a large exophytic mass extruding from the LMSB. There was necrosis leading to a fistula between the left and right mainstem bronchi distal to the carina. Pathology of the mass showed necrotic bronchial mucosa and cartilage with invasive mucormycosis. She underwent placement of a 10X40mm covered stent in LMSB. However, due to granulation tissue and recurrent mucus plugging, she needed a bronchoscopy every 3-4 weeks and multiple stent revisions. Despite these interventions, her respiratory symptoms did not change significantly. Ultimately, her airway was also complicated by tracheobronchomalacia (TBM) of the right main stem bronchus (RMSB). Subsequently a custom printed 3D silicone Y-stent from VisionAir was placed that allowed successful recanalization of LMSB and management of the TBM of RMSB simultaneously. The patient reported significant improvement in respiratory symptoms. She was maintained on Isavuconazole for mucormycosis suppression therapy DISCUSSION: Mucormycosis infections commonly occur in the pulmonary or rhino-cerebral region with high morbidity and mortality. Mucor can involve the major airways as well as rarely invade the tracheal cartilage leading to TBM. There is often granulation tissue, gray-white mucoid material, with edematous and necrotic airway. This can be associated with complex central airway obstruction. While the covered tracheobronchial stent (Bonastent) allowed us to recanalize LMSB, it was complicated by obstructive granulation tissue formation and mucous plugging requiring frequent stent revision to maintain stent patency. At the same time, the TBM in the right airway was contributing significantly to dyspnea and cough. While a standard silicon Y stent was considered for the management of bilateral mainstem bronchi disease, due to the significant distortion in airway anatomy this was not an ideal option. By using the VisionAir stent, we placed a custom stent that would best fit her airway anatomy. The patient had sustained improvement in her symptoms for several months following the procedure. CONCLUSIONS: This is the first case report of a custom designed and 3D printed stent for the treatment of benign central airway obstruction caused by tracheobronchial mucormycosis. Custom stents are a promising tool to individualize and tailor intervention for patients with complex airway anatomy. Reference #1: Tracheal Mucormycosis Pneumonia: A Rare Clinical Presentation. Satyawati Mohindra, Bhumika Gupta, Karan Gupta and Amanjit Bal. Respiratory Care November 2014, 59 (11) e178-e181 Reference #2: Keshishyan S, DeLorenzo L, Hammoud K, Avagyan A, Assallum H, Harris K. Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management. J Thorac Dis. 2017;9(6):1707-1724. doi:10.21037/jtd.2017.06.31 Reference #3: Leon CA, Inaty H, Urbas A, Grafmeyer K, Machuzak M, Sethi S, Gildea T. Early outcomes with 3D printing and airway stents. CHEST 2019 annual meeting s. DISCLOSURES: No relevant relationships by Sisir Akkineni No relevant relationships by Kelly Daymude No relevant relationships by Wissam Jaber No relevant relationships by Abesh Niroula
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SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Peripheral pulmonary nodule biopsy can be challenging based on its location and size. Robotic bronchoscopy is augmenting peripheral navigation, allowing for approximation of peripheral nodules. The diagnostic yield is variable and is primarily dependent upon operator experience, selection of biopsy equipment and nodule texture. Hard pulmonary nodules are difficult to biopsy with a needle, brush and forceps. We report a case of utilizing combined disposable 1.1 mm cryoprobe and robotic bronchoscopy to diagnose a right lower lobe nodule. CASE PRESENTATION: A 83-year-old woman with a remote history of non-Hodgkin's lymphoma presented with dyspnea and fatigue. 18F-FDG PET/CT revealed a 2.7 cm hypermetabolic nodule with central photopenia in the right lower lobe (RLL) along with patchy bilateral ground-glass opacities related to COVID-19 infection. After a few weeks, robotic navigation was used for approximation of the RLL superior segment nodule. Under fluoroscopic and radial guidance with circumferential signal, 6 forcep biopsies and 5 fine needle aspirations with 21-gauge needle yielded a non-diagnostic sample. A decision was made to utilize a 1.1 mm disposable cryoprobe, which was inserted through the opening made by the forceps into the target lesion. Six cryo biopsies were obtained with 4-6 seconds freeze time. Minimal bleeding was encountered and no pneumothorax occurred. Histopathological examination revealed necrotizing granulomatous inflammation. DISCUSSION: To the best of our knowledge, this is the first reported case of combination 1.1 mm disposable cryoprobe biopsy with robotic bronchoscopy. Interventional pulmonologists are primarily using cryo probe for mechanical tumor debulking and peripheral lung biopsy for diagnosis of interstitial lung disease. The use of a 1.1 mm cryoprobe under robotic guidance allows for well-preserved tissue samples and possibly boosting diagnostic yield. The advantage of the 1.1 mm cryoprobe lies with its size and excellent flexibility. The robotic platform also corrects for any unwanted deflection. One limitation of using a flexible cryoprobe is its blunt tip, requiring an additional step in gaining access to nodules located outside the airway with either the biopsy needle or forceps. Future improvements in cryoprobe design with a sharp tip may address this limitation. CONCLUSIONS: Combining 1.1 mm disposable cryoprobe with robotic bronchoscopy is safe and can be considered as an adjunct to conventional biopsy, allowing for well-preserved tissue. Further prospective studies to evaluate its performance and safety is warranted. Reference #1: Kho SS, Chai CS, Nyanti LE, et al. Combination of 1.1 mm flexible cryoprobe with conventional guide sheath and therapeutic bronchoscope in biopsy of apical upper lobe solitary pulmonary nodule. BMC Pulm Med. 2020. 158(20). doi.org/10.1186/s12890-020-01199-3 Reference #2: Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047 Reference #3: Sahajal Dhooria, Inderpaul Singh Sehgal, Ashutosh NA Digambar Behera, Ritesh Agarwal. Diagnostic Yield and Safety of Cryoprobe Transbronchial Lung Biopsy in Diffuse Parenchymal Lung Diseases: Systematic Review and Meta-Analysis. Respiratory Care. 2016. 61(5):700-712. doi.org/10.4187/respcare.04488 DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Abid Khokar No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon No relevant relationships by Melinda Wang
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SESSION TITLE: Obstructive Lung Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION: 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1: Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https://doi.org/10.4103/ijri.IJRI_340_18 Reference #2: Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https://doi.org/10.1155/2012/242579 Reference #3: Subcutaneous Emphysema in Acute Asthma: A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI: 10.4187/respcare.03750 DISCLOSURES: No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez