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1.
Eur J Med Res ; 27(1): 218, 2022 Oct 28.
Article in English | MEDLINE | ID: covidwho-2108966

ABSTRACT

PURPOSE: This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors. METHODS: We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed. RESULTS: A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes. CONCLUSIONS: Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.


Subject(s)
Respiratory Distress Syndrome , Respiratory Insufficiency , Child , Humans , Infant , Child, Preschool , Respiration, Artificial/adverse effects , Retrospective Studies , Intensive Care Units, Pediatric , Risk Factors , Respiratory Distress Syndrome/epidemiology , Respiratory Distress Syndrome/therapy , Intensive Care Units
2.
Cureus ; 14(9): e29651, 2022 Sep.
Article in English | MEDLINE | ID: covidwho-2100371

ABSTRACT

Emphysematous urinary tract infections (EUTIs) are rare, severe, and suppurative infections affecting various parts of the urinary tract. We report a case of a 75-year-old male presenting with hematuria and generalized weakness with uncontrolled diabetes mellitus (DM) and hypertension. He tested positive for COVID-19 on the second day of hospital admission. A non-contrast-enhanced CT of the abdomen and pelvis revealed gas within the left renal parenchyma, walls of the left ureter, and urinary bladder, establishing the diagnosis of EUTIs. The patient was treated using intravenous antibiotics without any surgical intervention, and four weeks later was stable and transported to long-term acute care (LTAC) facility. DM is the most common risk factor for the development of EUTIs and Escherichia coli is the most common causative pathogen.

3.
Medicina (Kaunas) ; 58(11)2022 Oct 26.
Article in English | MEDLINE | ID: covidwho-2090278

ABSTRACT

For COVID-19 pneumonia, many manifestations such as fever, dyspnea, dry cough, anosmia and tiredness have been described, but differences have been observed from person to person according to age, pulmonary function, damage and severity. In clinical practice, it has been found that patients with severe forms of infection with COVID-19 develop serious complications, including pneumomediastinum. Although two years have passed since the beginning of the pandemic with the SARS-CoV-2 virus and progress has been made in understanding the pathophysiological mechanisms underlying the COVID-19 infection, there are also unknown factors that contribute to the evolution of the disease and can lead to the emergence some complications. In this case report, we present a patient with COVID-19 infection who developed a massive spontaneous pneumomediastinum and subcutaneous emphysema during hospitalization, with no pre-existing lung pathology and no history of smoking. The patient did not get mechanical ventilation or chest trauma, but the possible cause could be severe alveolar inflammation. The CT results highlighted pneumonia in context with SARS-CoV-2 infection affecting about 50% of the pulmonary area. During hospitalization, lung lesions evolved 80% pulmonary damage associated with pneumomediastinum and subcutaneous emphysema. After three months, the patient completely recovered and the pneumomediastinum fully recovered with the complete disappearance of the lesions. Pneumomediastinum is a severe and rare complication in COVID-19 pneumonia, especially in male patients, without risk factors, and an early diagnosis can increase the chances of survival.


Subject(s)
COVID-19 , Mediastinal Emphysema , Subcutaneous Emphysema , Humans , Male , Mediastinal Emphysema/diagnosis , Mediastinal Emphysema/etiology , COVID-19/complications , SARS-CoV-2 , Tomography, X-Ray Computed/methods , Subcutaneous Emphysema/etiology , Subcutaneous Emphysema/complications
4.
Tanaffos ; 20(4): 368-372, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-2073854

ABSTRACT

The novel coronavirus infection is a global health concern in 2020. Computerized tomography (CT) scan has an important role in diagnosis and follow-up with the course of the disease. The most common radiologic findings in patients are bilateral peripheral patchy ground-glass opacities and consolidations. Although in a few cases, as we reported, we encountered some rare manifestations such as pneumothorax, pneumomediastinum, and subcutaneous emphysema, which imply distinct concerns about the management and outcome of the disease. Pulmonary interstitial emphysema develops due to an increase in alveolar pressure or because of alveolar rupture, secondary to alveolar membrane damage by the virus and proceed to such a complication. Therefore, it is crucial to be aware of the complications of novel coronavirus infection in the deterioration of the disease.

5.
Chest ; 162(4):A2594, 2022.
Article in English | EMBASE | ID: covidwho-2060971

ABSTRACT

SESSION TITLE: Late Breaking Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Pulmonary embolism (PE) is a common form of thromboembolism which has a variable and non-specific presentation that can often be fatal. The Simplified Pulmonary Embolism Severity Index (sPESI) which includes hemodynamic parameters of perfusion has been shown to correlate with 30-day mortality in patients with acute PE. The purpose of this quality improvement project was to compare how lactate and sPESI perform in predicting clinical outcomes at our institution with the hopes of developing institutional guidelines for management of patients admitted with an acute PE. METHODS: We conducted a single center retrospective analysis on patients admitted to the intensive care unit with a new diagnosis of PE between the years 2016-2021. Patients were identified using ICD-9 CM codes. Exclusion criteria included current or prior positive testing for SARS-CoV-2 (COVID-19). We performed univariate, multivariate, and ROC (Receiver Operating Characteristic) analysis to assess correlations between all cause mortality, lactate, and sPESI. Both lactate and sPESI were included as continuous variables. Our covariates included age, sex, Body Mass Index, prior or current history emphysema/COPD, smoking, CKD, diabetes, cancer, atrial fibrillation, and CHF. All analysis was carried out using software R version 3.6.3. RESULTS: Of the 161 patients who were included in the study, the mean age was 60 years (SD 17 years) and 38% (61/161) were females. 31 patients (19.3%) were deceased. Mean BMI of study participants was 29.9 kg/m2. Comorbidities included 9.9% (16/161) with emphysema/COPD, 44% (71/161) with active or prior history of smoking, 6% (10/161) with CKD, 12% (20/161) with diabetes, 15% (24/161) with diagnosis of cancer, 15% (24/161) with atrial fibrillation, 15% (24/161) with history of CHF. We found that in univariate analysis, both sPESI (p=3.4*10

6.
Chest ; 162(4):A2587, 2022.
Article in English | EMBASE | ID: covidwho-2060968

ABSTRACT

SESSION TITLE: Lung Transplantation: New Issues in 2022 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: This population-based study describes the changing demographic trends of Lung Transplants (LT) across the United States (U.S.) over the last two decades (2001 vs 2021). METHODS: We utilized the Organ Procurement and Transplantation Network (OPTN) registry to gather data on LT recipients across the U.S. for the year 2001 and 2021. Total yearly lung transplant numbers were recorded from 1988 to 2021. The recipients were categorized into subgroups based on age (<1, 1-5, 6-10, 11-17, 18-49, 50-64 and >65 years), race (Whites, Blacks, Hispanic/Latino, Asians, and Others) and most common diagnosis, and data was tabulated to compare for the years 2001 and 2021. RESULTS: From 1988 to 2021, 46,109 LTs were performed in the U.S. The yearly LT recipients increased from 1,059 in 2001 to 2,524 in 2021. The most common reason for LT was Emphysema/COPD (Chronic Obstructive Pulmonary Disease) in 2001 (n=464) and IPF (Idiopathic Pulmonary Fibrosis) in 2021 (n=899). In both 2001 and 2021, most LT recipients were in the age group 50-64 years (45.8% vs 58.1%) but the proportion of patients > 65 years receiving LT increased noticeably from 3.4% in 2001 to 36.9% 2021. Most LT recipients in both 2001 vs 2021, had “O” blood group (~ 45%). White patients comprised the majority of those registered for and those who underwent LT in both 2001 (n=940;88.80%) and 2021 (n=1,778;70.40%), although the relative percentage reduced by 18.40%. The relative percentages for Blacks, Asians, Hispanics receiving LTs increased from 2001 to 2021 by 2%, 3.3% and 11.8% respectively. In both 2001 and 2021, the states where maximum LTs were performed included– California (10.8% vs 12.6%), Pennsylvania (9.6% vs 9.3%) and Texas (7.3% vs 10.7%) while the states with the least LTs included– Connecticut, Mississippi, Oregon. CONCLUSIONS: There has been a general uptrend in the total number of LTs year-on-year, and the likely drop in LT recipients in 2020 and 2021 was due to the COVID-19 pandemic. The most common diagnosis for transplant changed from Emphysema/COPD in 2001 to IPF in 2021. There are appreciable racial and geographical disparities in receiving LTs in the United States but there are encouraging improvements in 2021 compared to 2001. There is an increasing trend of LTs in elderly patients (> 65 years), likely due to increased supportive care and improved life expectancy. CLINICAL IMPLICATIONS: Changes in socio-demographic trends in lung transplant recipients help us understand existing disparities and access to advanced lung disease centers so that we can better address these with equitable healthcare delivery tailored to changing transplant trends. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Manuel Hache Marliere No relevant relationships by paras malik No relevant relationships by Divya Reddy

7.
Chest ; 162(4):A2245, 2022.
Article in English | EMBASE | ID: covidwho-2060918

ABSTRACT

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky

8.
Chest ; 162(4):A2242, 2022.
Article in English | EMBASE | ID: covidwho-2060917

ABSTRACT

SESSION TITLE: Post-COVID-19 Outcomes SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Obesity, a risk factor for severe COVID-19 disease, multiplies the risk of hospitalization and mortality. Its impact in lung disease is mediated by altered inflammatory responses and respiratory mechanics. Studies of lung function among COVID-19 disease survivors have identified reduced TLC and DLCO as prominent changes in this population. Obesity, however, is associated with elevated DLCO in otherwise healthy individuals. The objective of this study was to evaluate whether this relationship was preserved among COVID-19 disease survivors. Additionally, we sought to analyze whether maximum FiO2, peak neutrophil-to-lymphocyte ratio (NLR), diabetes or smoking status had any effect in DLCO. METHODS: The charts of adult patients hospitalized with confirmed SaRS-CoV-2 infection between 3/20/2020 and 12/31/2021 were reviewed. Those who survived and later had a PFT were selected, and 73 patients met these criteria. Eighteen were excluded due to radiographic or prior PFT findings of emphysema (COPD or AATD) or ILD, and missing diffusion study data. Patients were stratified by BMI class. Patient characteristics were compared using ANOVA and Pearson correlation. Other outcomes were analyzed using linear regression. RESULTS: A total of 55 patients were included. Average age was 55.6 years. Average BMI and DLCO were distributed as follows: healthy (23.76;16.94), overweight (28.3;17.50), obesity classes I (32.3;18.86), II (37.8;17.68), and III (48.2;24.56). ANOVA shows a significant effect of BMI class on DLCO (F4,50=4.067, p=0.006). A significant positive correlation between BMI and DLCO was observed (r=0.392, p=0.003). When comparing BMI classes, Tukey’s HSD test shows that there was a significant difference only when patients classified as overweight (-22.9, p=0.01), or with obesity classes I (-20.2, p=0.02) or II (-24.0, p=0.005), were individually compared to obesity class 3. Regression analysis showed no significant effect of peak FiO2 (-0.056, p=0.07), NLR (-0.051, p=0.60), diabetes (-0.932, p=0.50), or smoking status (0.764, p=0.505). Overall regression between dependent and independent variables is not significant (F4,50=2.21, p=0.082). CONCLUSIONS: These findings suggest that higher obesity is associated with higher DLCO. This is consistent with the known effect of obesity on diffusion capacity, resulting from increased blood volume in the pulmonary circulation. The relationship was preserved even though most patients had DLCO below the percent predicted, as observed in studies of lung function among COVID-19 survivors. Notably, FiO2 and NLR did not have a significant effect on DLCO. CLINICAL IMPLICATIONS: Though patients surviving a COVID-19 hospitalization may have a reduced DLCO, the positive relationship between BMI and DLCO is similar to that observed in otherwise healthy obese individuals. DISCLOSURES: No relevant relationships by Mohammad Arabiat No relevant relationships by Justin Horner No relevant relationships by Harold Matos Casano No relevant relationships by Doug McElroy No relevant relationships by Karan Singh No relevant relationships by Michael Smith

9.
Chest ; 162(4):A2083, 2022.
Article in English | EMBASE | ID: covidwho-2060896

ABSTRACT

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration can affect ventilation-oxygenation dynamics causing significant morbidity and mortality in children and adults. Patient presentation can range from asymptomatic to life-threatening hypoxia. A thorough history and physical examination helps in narrowing differential diagnosis and provision of timely management. A myriad of complications can occur from aspirated Foreign body including recurrent pneumonia, lung abscess, obstructive emphysema, and death. Here we present a case of a patient with recurrent pneumonia from a chronically aspirated foreign body. CASE PRESENTATION: 37-year-old male with past medical history of a recent COVID-19 infection and bronchus intermedius endobronchial mass (squamous metaplasia on biopsy 2009) who presented with fever, chest pain, worsening dyspnea. Initial workup was consistent with severe sepsis. A CT chest showed complete collapse, cavitation in right lower lobe and presence of right bronchus stent. Patient was treated with IV fluids and antibiotics during the hospitalization. He underwent bronchoscopy for airway examination and bronchoalveolar lavage. Airway exam showed a large endobronchial mass in the bronchus intermedius. Endobronchial biopsies were taken, followed by tissue debulking using flexible forceps and cryoprobe. A yellow plastic foreign object was then visualized dislodged in the right lower lobe. This was successfully removed with grasping forceps. Patient had to be extubated and be reintubated to remove foreign object in one piece as it did not fit the endotracheal tube. Post debulking, bronchus intermedius and right lower lobe were patent and procedure was completed. Our patient responded well to treatment he was ultimately transitioned to oral antibiotics and discharged home with outpatient follow up. Repeat bronchoscopy 6 weeks later showed normal airways. DISCUSSION: Our case illustrated the importance of thorough investigation while treating patients with recurrent pneumonia, and this sometimes should include bronchoscopy with airway exam. In our case a bronchoscopy was done several years ago, however the foreign body was not identified as the cause of the endobronchial lesion. A lingering foreign body in the long run has significant morbidity as seen in our case despite appropriate treatment with antibiotics patient continued to have recurrent post obstructive pneumonias. Bronchoscopy remains the gold standard in definitive diagnosis and management of foreign body. Since the refinement of bronchoscopy and debulking, the rate of mortality from foreign body aspiration has been remarkably reduced. CONCLUSIONS: In summary patients with history suggestive of potential foreign body aspiration presenting with recurrent pneumonias at a particular anatomical location should prompt physicians to perform diagnostic bronchoscopy, which remains the gold standard for diagnosing of foreign body aspiration Reference #1: Foreign Body Aspiration Natan Cramer;Noel Jabbour;Melissa M. Tavarez;Roger S. Taylor. DISCLOSURES: No relevant relationships by Maria Abril No relevant relationships by Bilal Bangash No relevant relationships by Imran Tarrar

10.
Chest ; 162(4):A2079-A2080, 2022.
Article in English | EMBASE | ID: covidwho-2060895

ABSTRACT

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: Secondary spontaneous pneumothoraxes commonly occur in patients with cystic fibrosis (CF) and can be complicated by persistent air leak (PAL) due to bronchopleural or alveolopleural fistula. More recently, bronchoscopic placement of one-way endobronchial valves (EBV) for PAL have been explored. We present the first case series of patients with CF who developed secondary spontaneous pneumothoraxes and were successfully treated with EBV. CASE PRESENTATION: A 30-year-old female with CF (F508del/dupex6B-10) and history of pneumothorax, presented with acute hypoxic respiratory failure. She was found to have a right-sided pneumothorax. A chest tube was placed, with a continuous air leak for 4 days. She was a suboptimal surgical candidate given extensive apical lung disease, making localization of the air leak difficult. In addition, the increased tissue density would have made wedge resection challenging. After multidisciplinary discussion, the patient underwent placement of 5 Zephyr EBV (Pulmonx Inc., Redwood City, CA) for PAL. The lung had re-expanded, but there was still an intermittent air leak. She underwent pleurodesis with betadine. Her chest tube was removed 2 days later, and she was discharged. She was seen in the pulmonary clinic 5 days after being discharged and was noted to have recurrent right pneumothorax. She underwent chest tube placement with flutter valve. The chest tube was removed after 10 days. The patient was scheduled for removal of EBV 6 weeks after placement, but the procedure was delayed to symptomatic COVID-19 infection. EBV were eventually removed 12 weeks after placement. Pneumothorax has not recurred 6 weeks post EBV removal. A 53-year-old female with CF (394delTT/3272-26A-G) and a small right apical secondary spontaneous pneumothorax 3 months prior to hospitalization presented with progressive dyspnea. Imaging showed that the pneumothorax had enlarged. A chest tube was placed with continuous air leak. After a multidisciplinary discussion, 5 Zephyr EBV were placed 2 days later. There was immediate improvement of the pneumothorax, with almost no air leak. Her chest tube was removed 48 hours after placement of EBV, and patient was discharged on day 4. The EBV were removed 8 weeks later with no recurrence of pneumothorax 1 month after valve removal. DISCUSSION: To our knowledge this is the first case series describing the use of Zephyr EBV in CF patients with secondary spontaneous pneumothorax complicated by PAL. Although previous guidelines still recommend surgery and/or pleurodesis for PAL, this may not be the best option for patients with CF who may require lung transplantation. EBV are currently FDA approved for lung volume reduction to treat emphysema, but it is likely a viable non-surgical alternative for PAL. CONCLUSIONS: EBV is a well-tolerated treatment option for PAL due to secondary spontaneous pneumothoraxes. Reference #1: Bongers KS, De Cardenas J. Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema. J Cyst Fibros. 2020 Sep;19(5):e36-e38. doi: 10.1016/j.jcf.2020.03.014. Epub 2020 Apr 18. PMID: 32312675. Reference #2: Travaline JM, McKenna RJ Jr, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, Criner GJ;Endobronchial Valve for Persistent Air Leak Group. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009 Aug;136(2):355-360. doi: 10.1378/chest.08-2389. Epub 2009 Apr 6. Erratum in: Chest. 2009 Sep;136(3):950. PMID: 19349382. Reference #3: Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417-423. doi: 10.1016/j.chest.2017.02.020. Epub 2017 Mar 4. PMID: 28267436;PMCID: PMC6026238. DISCLOSURES: No relevant relationships by Bryan Benn no disclosure on file for Julie Biller;No relevant relationships by Rose Franco Speaker/Speaker's Bureau relationship with Biodesix Please note: 2018 - present by Jonathan Kurman, value=Honoraria Consultant relationship with Level Ex Please note: 2018 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Medtronic Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Pinnacle Biologics Please note: 2020 - present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Consultant relationship with Boston Scientific Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Cook Medical Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Erbe Please note: 2021 - present by Jonathan Kurman, value=Honoraria research panel relationship with Intuitive Please note: 2020 - present by Jonathan Kurman, value=Honoraria Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Pulmonx Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Travel relationship with Ambu Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Travel Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Ambu Please note: 2022-present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Veracyte Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Honoraria No relevant relationships by Shreya Podder

11.
Chest ; 162(4):A2006-A2007, 2022.
Article in English | EMBASE | ID: covidwho-2060886

ABSTRACT

SESSION TITLE: Occupational and Environmental Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: We describe a case of acute progression of chronic hypersensitivity pneumonitis (HP) in an adult, previously misdiagnosed as COPD for 13 years due to severe emphysematous changes seen on imaging. He was also found to have acutely worsened disease as a result of Covid-19. CASE PRESENTATION: A 64-year-old male presented to the pulmonary clinic with dyspnea on minimal exertion. He reported respiratory complaints for 13 years, treated with 2 L/min of oxygen overnight, and budesonide-formoterol and tiotropium inhalers. These complaints were previously associated with brief occupational mold exposure and possible COPD. His respiratory distress worsened one year ago when he was hospitalized for Covid-19. On discharge, his oxygen requirement had increased to 6 L/min. CT chest showed air-trapping in the mid-zones bilaterally, mosaic attenuation, and peri-bronchial thickening. PFTs showed an FEV1 33% and FVC 55% of predicted, consistent with severe obstruction and reduction in lung volume. As the patient was a lifetime non-smoker, alternative diagnoses were pursued. Alpha-1 antitrypsin levels and immunologic testing, including scleroderma and myositis panels, were within normal limits. Positive findings included CCP IgG/IgA antibodies at 96 units and HP panel positive for pigeon serum antibodies. Prompted by this testing, the patient revealed that he had parakeets in his home for the past 15 years. He also reported significant symptom improvement on occasions that he took a course of steroids. Based on these findings, a diagnosis of chronic fibrotic hypersensitivity pneumonitis with bronchiolitis obliterans was considered. The patient's severe airflow obstruction and respiratory failure precluded surgical lung biopsy. Empiric management was initiated with 30 mg of prednisone daily with a slow taper and instruction to eliminate exposure to exotic birds. DISCUSSION: HP is commonly caused by inhalation of and sensitization to an aerosolized environmental antigen;a common subtype is bird fancier's lung due to repetitive exposure of avian antigen. Continuous antigen exposure increases the risk for development of fibrosis, which was also seen in our patient. The most commonly described radiologic findings in HP are ground-glass opacities, ill-defined centrilobular nodules, and focal areas of air trapping resulting in mosaic attenuation and fibrosis. More than 20% lymphocytosis on bronchoalveolar lavage is also a sensitive tool in detecting alveolitis. The relationship between Covid-19 and disease progression in HP is not well studied. CONCLUSIONS: Chronic hypersensitivity pneumonitis from avian antigens, or Bird fancier's lung, can present with severe emphysematous changes on CT imaging, along with obstructive pattern of PFTs. This should be an important differential, especially in patients who are non-smokers. Covid-19 causes disease progression in HP, this relationship needs to be further explored. Reference #1: Funke M., Fellrath J.-M. Hypersensitivity pneumonitis secondary to lovebirds: a new cause of bird fancier's disease. Eur. Respir. J. 2008;32:517–521. DOI: 10.1183/09031936.00108507 Reference #2: Pereira C., Gimenez A., Kuranishi L., Storrer K. Chronic hypersensitivity pneumonitis. J. Asthma Allergy. 2016;9:171–181. DOI: 10.2147/JAA.S81540 Reference #3: C.S. Glazer, C.S. Rose, D.A. Lynch Clinical and radiologic manifestations of hypersensitivity pneumonitis J. Thorac. Imag., 17 (4) (2002), pp. 261-272. DOI: 10.1097/00005382-200210000-00003 Morell F, Roger A, Reyes L, Cruz MJ, Murio C, Muñoz X Bird fancier's lung: a series of 86 patients. Medicine (Baltimore). 2008;87(2):110-130. DOI: 10.1097/MD.0b013e31816d1dda DISCLOSURES: No relevant relationships by Momina Amjad No relevant relationships by Amit Chopra No relevant relationships by Rafeh Safdar

12.
Chest ; 162(4):A1961-A1962, 2022.
Article in English | EMBASE | ID: covidwho-2060881

ABSTRACT

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

13.
Chest ; 162(4):A1814, 2022.
Article in English | EMBASE | ID: covidwho-2060869

ABSTRACT

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are reported as rare complications of COVID-19 pneumonia in various observational studies. The purpose of this study is to investigate the incidence of these complications and their outcome in hospitalized patients with COVID-19 pneumonia, at our inner-city hospital system in Central Pennsylvania. METHODS: We performed a retrospective chart review of the patients admitted with COVID-19 pneumonia from March 2020 to March 2021 in 3 different hospitals located in central Pennsylvania. Data on their demographics, pre-existing comorbidities, inpatient location, radiologic findings, timeline of events, mode of oxygenation and ventilation, hematology, chemistry profile and inflammatory markers were obtained. Patients with known inciting events for barotrauma, other than COVID-19 pneumonia were excluded from our analysis. RESULTS: The mean age of patient cohort was 66 years (SD 14.07). Almost fifty two percent were obese with BMI more than 30 kg/m2 and 69.5% were male. Only 11.4% of the study population had history of COPD and majority (63.6%) did not have history of smoking. Out of 31,260 inpatients, only 44 (0.0014 %) patients spontaneously developed thoracic free air. Among them, 33 (75%) had pneumothorax, and 22 (50%) needed chest tube for the management. 18 (40.9%) had pneumomediastinum, and 20 (45.5%) had subcutaneous emphysema. These are not exclusive findings and some patients had free air in more than one location. Thirty (68.2%) patients were admitted to ICU (Intensive Care Unit), 20 (45.5%) patients needed invasive ventilation and 26 (61.4%) had in-hospital mortality. Mortality in ICU was significantly high (86.67%) compared to non-ICU patients (7.14%). The average duration of hospitalization was 28.18 days (SD 25.46). CONCLUSIONS: Incidence of spontaneous thoracic free air complication in COVID –19 pneumonia is a rare phenomenon. In our patient cohort, occurrence of these events was seen irrespective of type of oxygen delivery and ventilation. However, patients having these complications had a high rate of ICU admission. Mortality is significantly high especially in patients admitted to ICU. CLINICAL IMPLICATIONS: Spontaneous thoracic free air complication in COVID-19 pneumonia is rare but can be a marker of poor prognosis. Vaccination status of study population was unknown, therefore the role of vaccination to prevent these complications and their outcome needs to be explored. DISCLOSURES: No relevant relationships by Yi-Ju Chen No relevant relationships by Anatoliy Korzhuk No relevant relationships by Rajan Pathak No relevant relationships by Navitha Ramesh No relevant relationships by Michaela Sangillo

14.
Chest ; 162(4):A1670, 2022.
Article in English | EMBASE | ID: covidwho-2060852

ABSTRACT

SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin

15.
Chest ; 162(4):A1601, 2022.
Article in English | EMBASE | ID: covidwho-2060848

ABSTRACT

SESSION TITLE: Outcomes in Pneumonia and NTM SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The number of patients with respiratory symptoms who underwent computed tomography (CT) for suspected COVID-19 pneumonia is high. In this study, we decided to investigate the incidental non-COVID 19 related pulmonary findings due to a large number of CT scans. METHODS: It was retrospective study in Funda Hospital of Heath Ministry of Azerbaijan, Baku city and the number of enrolled patients to the study was 2567 from 1st of October 2020 to 10 30 th of March 2021.In all patients the positive RT-PCR test for COVID-19 were confirmed.Depending on COVID-19 viral pneumonia findings in lung there were two groups :1) 1589 patients with non-COVID-19 viral pneumonia;2) 978 pateins with COVID-19 viral pneumonia RESULTS: In our study CT screening for COVID-19 viral pneumonia has detected typical viral pneumonia in 38.1%(978 of 2567) patients and in 61.9%(1689 of 2567 ) was not found CT abnormalities accordingly COVID-19 viral pneumonia.Among typical CT suggested COVID19 viral pneumonia patients the incidental pulmonary findings were found in 197(20,15%) cases, was significantly common compared to non- CT suggested viral pneumonia (OR 5.34 [0.94-12.57]95%CI;p<0.001).Common CT incidental pulmonary finding was solitary pulmonary nodule (56[28.43%] vs 21[29.58%];p<0.01) and further histopathological evaluation has detected lung cancer(primary and metastatic) in 19 patients(24.68%). Bronchectasis (commonly small size syctic and tubular bronchectasis) which was also commonest in patients with viral pneumonia (OR 2.78[0.75-6.43]95%CI;p<0.004). Emphysema was found in 69(2.69%) and was common in patients with pulmonary viral manifestation(p<0.01).Lung tuberculosis with further histological and mycobacterial confirmation was as incidentally finding in 49 cases (1.87%)( focal changes, lung inflitrate,cavitation) and commonly was found in patients with CT suggested viral pneumonia (OR 2.11[0.69-5.86]95%CI;p=0.006).Pulmonary sarcoidosis was found totally in 38(1.48%) and was common in patients with viral pneumonia (p<0.01).Idiopatic pulmonary fibrosis(IPF) with typical features of usual interstitial pneumonia(UIP) was found in 31(1,21%) patients and was commonly in male with smoking history and older age (>60 years).Common risk factors for incidental pulmonary findings were:male gender(p<0.01);tobacco smoke (p<0.01);older age(p<001);previous history of lung tuberculosis(p<0.05) comorbidities such as DM and autoimmune disorders(p<0.01) CONCLUSIONS: Risk factors for COVID-19 related viral pneumonia and incidental pulmonary findings in CT scan are similar and so incidental pulmonary findings are common in CT screening for COVID-19 related viral pnemonia.Incidental pulmonary abnormalities were not associated with increased risk for ICU admission and mortality of patients. CLINICAL IMPLICATIONS: Clinicians in paracitce with COVID-19 patients,for pulmonologists,radiologists, respiratory educators, thoracic oncologists DISCLOSURES: No relevant relationships by Alizamin Sadigov

16.
Chest ; 162(4):A1418, 2022.
Article in English | EMBASE | ID: covidwho-2060815

ABSTRACT

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel

17.
Chest ; 162(4):A1327-A1328, 2022.
Article in English | EMBASE | ID: covidwho-2060807

ABSTRACT

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

18.
Chest ; 162(4):A1304, 2022.
Article in English | EMBASE | ID: covidwho-2060800

ABSTRACT

SESSION TITLE: Difficult Diffuse Lung Disease SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Common Variable Immunodeficiency (CVID) is one of the most common humoral immunodeficiency disorders and usually manifests as infectious complications. However, noninfectious complications such Granulomatous-Lymphocytic Interstitial Lung Disease (GLILD) can convey a much poorer prognosis in patients with CVID. In this case report, we present a patient with GLILD who presented with cough and shortness of breath. CASE PRESENTATION: A 66 year old female with past medical history of provoked DVT (off anticoagulation), cervical cancer (s/p resection) presented to pulmonology clinic with complaints of chronic cough and shortness of breath on exertion. She had a negative smoking history and no occupational exposures. She was up to date on vaccinations and COVID was negative. Vitals were stable and physical exam was normal including clear breath sounds. CXR revealed emphysema and hazy opacities in the lung bases. PFTs demonstrated moderate obstructive pattern with no response to bronchodilator, normal lung volumes, and DLCO of 76%. Due to lack of improvement in her cough, CT Chest was done which revealed diffuse pulmonary nodules, bronchiectasis with possible atelectasis or scarring in the RML and lingula, and a prominent subcarinal lymph node. EBUS TBNA of station 7 returned negative for malignancy. Culture showed polymicrobial growth with negative AFB and fungi. Patient was treated without antibiotics, but due to family history of immunodeficiency, immunoglobulin panel was sent which returned low IgG subclasses. She then received IVIG. However, given the centrilobular nodules and lack of response to IVIG, repeat bronchoscopy with TBBx and BAL was performed. BAL revealed lymphocytic predominance and tissue biopsy showed non-caseating granulomas and negative cultures. Eventually patient was diagnosed with GLILD and started on 6 weeks of prednisone 40 mg daily along with PJP prophylaxis. However, her symptoms remained same and rituximab was prescribed with improvement in the symptoms. DISCUSSION: Although recurrent sinopulmonary infections are common in CVID patients, if clinical response to IVIG is minimal to none, GLILD should be considered on the differential. Centrilobular nodules and ground glass opacities should raise suspicion of GLILD and tissue sample should be obtained in these patients to confirm the diagnosis. Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. CONCLUSIONS: Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. Reference #1: Hurst JR, Verma N, Lowe D, Baxendale HE, Jolles S, Kelleher P, et al. British lung foundation/United Kingdom primary immunodeficiency network consensus statement on the definition, diagnosis, and management of granulomatous-lymphocytic interstitial lung disease in common variable immunodeficiency disorders. J Allergy Clin Immunol Pract. (2017) 5:938– 45. doi: 10.1016/j.jaip.2017.01.021 DISCLOSURES: No relevant relationships by Benjamin Butler No relevant relationships by Abdulmetin Dursun No relevant relationships by Badri Giri No relevant relationships by Emily Smallwood

19.
Chest ; 162(4):A1074, 2022.
Article in English | EMBASE | ID: covidwho-2060765

ABSTRACT

SESSION TITLE: Biological Markers in Patients with COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Pandemic SARS-CoV-2 infection (COVID-19), like other respiratory viruses, caused a massive incidence of acute respiratory distress syndrome (ARDS). Prior literature showed that influenza infection results in a significant increase in the level of circulating High Mobility Group Box 1 (HMGB1) in infected mice, cotton rats, and in humans;and a small molecule inhibitor of HMGB1 blocked lung pathology and lethality in influenza-infected mice and cotton rats. Moreover, HMGB1 has also been shown to be elevated in the serum of patients with ARDS and is an indicator of increased mortality. Gastrin Releasing Peptide (GRP) has been implicated in bronchopulmonary dysplasia, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, and fibrosis. In addition to HMGB1, GRP represents a novel DAMP that, when targeted therapeutically in influenza-infected mice, is highly protective. The interaction between GRP and HMGB1 is currently under study. We examined if these DAMPS are associated with poor clinical outcomes in patients with COVID-19 ARDS. METHODS: Deidentified patient plasma and serum samples were obtained from discarded, clinical blood samples from 100 patients with COVID-19 admitted to UMMC's intensive care unit (ICU). Demographic and clinical data were collected from the patient’s electronic medical record. HMGB1 and GRP ELISA kits were used to analyze their concentrations in patients’ sera at Day 1 of admission to ICU. Cox proportional hazards models were used to examine the relationship between risk factors and severity of hypoxemia (P/F ratio), need for mechanical ventilation, and need for mechanical circulatory support (VV-ECMO). RESULTS: The average age of study participants was 59.1 years of which 59.2% were men and 57.1% were African American. The mean BMI was 34.3 kg/m2. The prevalence of hypertension, hyperlipidemia, diabetes, pulmonary and cardiovascular disease was 57.1%, 26.5%, 42.9%, 32.7%, and 42.9%, respectively. We found that GRP concentration was associated with worsening hypoxemia (mild 31.9, mod. 42.7, severe 79.0 ng/ml;p=0.014), requirement for mechanical ventilation (No 40.1, Yes 61.5 ng/ml;p=0.063), and need for VV-ECMO (No 48.6, Yes 93.1 ng/ml;p=0.026). HMGB1 concentration was associated with worsening hypoxemia (mild 24.4, mod. 55.1, severe 40.9 ng/ml;p=0.021) but did not correlate with other outcomes. CONCLUSIONS: GRP and HMGB1 have been previously implicated in the pathogenesis of viral infections, such as influenza, and ARDS in animal models and human. Our results suggest that these DAMPs maybe associated with severity of disease in critically ill patients with COVID-19 infection. CLINICAL IMPLICATIONS: Future studies should elucidate the specific cellular and biochemical pathways implicated in pathogenesis of ARDS, identify whether HMGB1 and GRP could be potential biomarkers for severe illness outcomes, and test novel anti-HMGB1 and GRP therapeutics in ARDS. DISCLOSURES: No relevant relationships by Fahid Alghanim no disclosure on file for Jeffrey Hasday;Consultant relationship with Guidepoint Please note: $1-$1000 by Carl Shanholtz, value=Consulting fee stock holder relationship with Teva Pharmaceuticals Please note: $1001 - $5000 by Carl Shanholtz, value=stock iinvestor relationship with illumina Please note: $1001 - $5000 by Carl Shanholtz, value=options No relevant relationships by Kari Ann Shirey No relevant relationships by Mohan Tulapurkar No relevant relationships by Stefanie Vogel

20.
Chest ; 162(4):A1061-A1062, 2022.
Article in English | EMBASE | ID: covidwho-2060763

ABSTRACT

SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Air outside the lungs, bowel, or paranasal cavities suggests critical pathology. Pneumoperitoneum is a classic example in which free abdominal air may signify hollow viscus injury and the need for emergent surgical management. Ectopic gas can also be secondary to barotrauma secondary to mechanical ventilation and concurrent lung injury;the latter being findings often observed in COVID pneumonia (1,2,3). Our case of extensive intramedullary gas in the setting of COVID pneumonia is an example of extensive dissecting air related to barotrauma, but also illustrates how it mimics dire cases of pneumoperitoneum. Therefore, it is an imaging finding that intensivists caring for COVID pneumonia patients should be aware of. CASE PRESENTATION: A 52-year-old male with mild restrictive lung disease from congenital scoliosis developed COVID pneumonia and hypoxic respiratory failure requiring intubation. Clinical course was complicated by renal failure, deep venous thromboses, and radial artery occlusion. CT evaluation revealed large volume upper abdominal pre-peritoneal gas, pneumoperitoneum, soft tissue and intramedullary gas within bilateral ribs and multiple vertebral bodies. Despite reassuring abdominal exams, the patient deteriorated. The patient was placed on comfort care and expired. DISCUSSION: Intramedullary gas refers to the presence of air within the cortical or trabecular bone, bone marrow, or medullary cavity. It is an exceedingly rare imaging finding which was first described in ischemic vertebral collapse and osteomyelitis (4,5). Differential diagnosis includes infection, trauma, degenerative and iatrogenic causes (5,6). Embryologically, fascial layers of the thorax and periosteal coverings of the thoracic osseous structures are derived from the mesoderm, thus creating a continuum between the lungs, surrounding soft tissues, peritoneum, and surrounding osseous structures, and therefore allowing gas to travel between the lung and intramedullary space (7). As cases of COVID pneumonia with ARDS increase, we are becoming aware of the increasing incidence of ectopic air, and the poor prognosis and increased mortality that results (1). Therefore, the finding of intramedullary gas is an important prognostic indicator that the clinician should be aware of. CONCLUSIONS: Several recent studies demonstrate increased mortality in COVID patients who develop ectopic gas as a result of barotrauma and/or acute lung injury (1,2,3). As such the clinician should be aware of these findings, which include pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, pre-peritoneal air, and intramedullary gas for early recognition. Reference #1: 1. Lemmers DHL, Abu Hilal M, Bnà C, Prezioso C, Cavallo E, Nencini N, Crisci S, Fusina F, Natalini G. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Res. 2020 Nov 16;6(4):00385-2020. doi: 10.1183/23120541.00385-2020. PMID: 33257914;PMCID: PMC7537408. Reference #2: 2. Guven BB, Erturk T, Kompe Ö, Ersoy A. Serious complications in COVID-19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax. Epidemiol Infect. 2021 Jun 8;149:e137. doi: 10.1017/S0950268821001291. PMID: 34099076;PMCID: PMC8207553. Reference #3: 3. Tetaj N, Garotto G, Albarello F, Mastrobattista A, Maritti M, Stazi GV, Marini MC, Caravella I, Macchione M, De Angelis G, Busso D, Di Lorenzo R, Scarcia S, Farina A, Centanni D, Vargas J, Savino M, Carucci A, Antinori A, Palmieri F, D'Offizi G, Ianniello S, Taglietti F, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L, Icu Covid-Study Group. Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital. J Clin Med. 2021 Nov 29;10(23):5608. doi: 10.3390/jcm10235608. PMID: 34884310;PMCID: PMC8658701. DISCLOSURES: Researc support relationship with 4D Medical Please note: March 2021 Added 04/04/2022 by Anu Brixey, value=Grant/Research Support No relevant relationships by raluca mccallum

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