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1.
Can J Respir Ther ; 58: 155-161, 2022.
Article in English | MEDLINE | ID: covidwho-2091555

ABSTRACT

Background: We report the characteristics, timing, and factors related to the decision to perform a tracheostomy in patients with confirmed COVID-19 infection admitted to eight Italian intensive care units (ICUs). Materials and methods: Prospective observational cohort study of patients with COVID-19 disease on mechanical ventilation. Long-term functional impairment (up to 180 days' post-hospital discharge) was assessed using the Karnofsky scale. Kaplan-Meier analysis assessed differences in survival and freedom from tracheostomy in relation to ICU stay. Cox regression model was used to assess which variables impacted on tracheostomy as a categorical outcome. Results: A total of 248 patients were recruited in the eight participating ICUs. Patients undergoing tracheostomy (n = 128) had longer ICU (25 (18-36) vs. 10 (7-16), P = 0.001) and hospital (37 (26.5-50) vs. 19 (8.5-34.5) P = 0.02) stays. ICU and hospital mortality of patients tracheostomized was 34% and 37%, respectively. Cumulative survival Kaplan-Meier analysis documented improved survival rates in patients undergoing tracheostomy (Log-Rank, Mantel-Cox = 4.8, P = 0.028). Median Karnofsky scale values improved over time but were similar between survivors receiving or not receiving tracheostomy. No healthcare worker involved in the tracheostomy procedure developed COVID-19 infection during the study period. Conclusions: Patients with COVID-19 infection who underwent tracheostomy had a better cumulative survival but similar long-term functional outcomes at 30, 60, and 180 days after hospital discharge.

2.
JA Clin Rep ; 8(1): 88, 2022 Oct 26.
Article in English | MEDLINE | ID: covidwho-2089253

ABSTRACT

BACKGROUND: SARS-CoV-2 infection has many manifestations, including otolaryngological symptoms. CASE PRESENTATION: A 60-year-old man with severe dyspnea underwent endotracheal intubation followed by 68 h of mechanical ventilation. After extubation, he left the ICU without any significant complications. Four days after the extubation, he developed dyspnea, which deteriorated the next 2 days, and stridor became evident. A fiberoptic laryngoscope revealed bilateral vocal cord edema and paralysis, which required an emergency airway. We decided to perform an awake tracheostomy under local anesthesia while considering protection for airborne infection to healthcare providers. The tracheostomy was closed when the edema and paralysis of the vocal cords were ameliorated. CONCLUSIONS: A COVID-19 patient who underwent injurious ventilation developed vocal cord paralysis and edema 6 days after extubation, leading to an emergency tracheostomy. Close attention to the upper airway of COVID-19 patients is essential since the pathophysiology of the present incident may be specific to the viral infection.

3.
Cureus ; 14(9): e29633, 2022 Sep.
Article in English | MEDLINE | ID: covidwho-2072223

ABSTRACT

Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.

4.
Oto-Rhino-Laryngology Tokyo ; 64(3):145-149, 2021.
Article in Japanese | EMBASE | ID: covidwho-2067222

ABSTRACT

Reverse -transcription polymerase chain reaction (RT-PCR)testing is necessary for the definitive diagnosis of coronavirus disease 2019(COVID-19), and is most often performed on pharyngeal swabs. However, it has become clear that even if the RT-PCR is negative, COVID-19 cannot be ruled out altogether. We encountered a patient who developed COVID-19 after a tracheostomy. He developed fever and respiratory failure and was suspected as having developed COVID-19, but RT-PCR conducted on upper airway specimens was negative twice in succession;a third RT-PCR test conducted on a sputum specimen later confirmed a positive result for severe acute respiratory syndrome coronavirus 2(SARS-CoV-2). In cases with clinically suspected infection with SARS-CoV-2, RT-PCR should be repeated, and lower respiratory tract specimens should be used from the beginning if the infection occurs before or after tracheostomy. Copyright © 2021 Society of Oto-Rhino-Laryngology Tokyo. All rights reserved.

5.
Indian Journal of Critical Care Medicine ; 26(10):1120-1125, 2022.
Article in English | EMBASE | ID: covidwho-2067000

ABSTRACT

Aims and objectives: In coronavirus disease-2019 (COVID-19) pneumonia, guidelines on timing and method of tracheostomy are evolving. The aim of the study was to analyze the outcomes of moderate-to-severe COVID-19 pneumonia patients who required tracheostomy and the safety with regard to the risk of transmission to the healthcare workers. Material(s) and Method(s): We retrospectively analyzed 30-day survival outcome of a total of 70 moderate-to-severe COVID-19 pneumonia patients on a ventilator, wherein tracheostomy was performed only in 28 (tracheostomy group), and the remaining were with endotracheal intubation beyond 7 days (non-tracheostomy group). Besides demographics, comorbidities, and clinical data including 30-day survival, and complications of tracheostomy were analyzed in both groups with respect to the timing of tracheostomy from the day of intubation. Healthcare workers were monitored for COVID-19 symptoms by carrying out periodical COVID tests. Result(s): The 30-day survival of the tracheostomy group was 75% as compared to 26.2% of the non-tracheostomy group. The majority of the patients (71.4%) had severe disease with PaO2/FiO2 (P/F ratio) <100. The first wave showed an 80% (4/5) whiles the second wave 100% (8/8) thirty days survival in the tracheostomy group performed before 13 days. All patients during the second wave underwent tracheostomy before 13 days with a median of 12th day from the day of intubation. These tracheostomies were performed percutaneous at the bedside, without any major complications and no transmission of disease to healthcare workers. Conclusion(s): Early percutaneous tracheostomy within 13 days of intubation demonstrated a good 30-day survival rate in severe COVID-19 pneumonia patients. Copyright © The Author(s). 2022.

6.
Med Sci (Basel) ; 10(4)2022 Sep 29.
Article in English | MEDLINE | ID: covidwho-2066255

ABSTRACT

During the COVID-19 pandemic, percutaneous tracheostomy proved to be an effective option in the management of patients with prolonged periods of intubation. In fact, among other things, it allowed early discharge from ICUs and contributed to reducing overcrowding in intensive care settings, a central and critical point in the COVID pandemic. As a direct consequence, the management and the weaning of frail, tracheostomized and ventilated patients was diverted to sub-intensive or normal hospitalization wards. One central challenge in this setting is the resumption of swallowing and oral feeding, which require interdisciplinary management involving a phoniatrician, ENT, pneumologist, and speech therapist. With this article, we aim to share the experience of a Swiss COVID-19 Center and to draw up a narrative review on the issues concerning the management of the tracheostomy cannula during swallowing resumption, integrating the most recent evidence from the literature with the clinical experiences of the professionals directly involved in the management of tracheostomized COVID-19 patients. In view of the heterogeneity of COVID-19 patients, we believe that the procedures described in the article are applicable to a larger population of patients undergoing tracheostomy weaning.


Subject(s)
COVID-19 , Deglutition , Humans , Pandemics , Switzerland , Tracheostomy/methods
7.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P74-P75, 2022.
Article in English | EMBASE | ID: covidwho-2064505

ABSTRACT

Introduction: The purpose of this study is to evaluate longterm laryngotracheal outcomes in patients who required 10 or more days of invasive mechanical ventilation (IMV) for COVID-19. Method(s): This is a prospective cohort study of patients previously hospitalized for active COVID-19 infection between January 2020 and March 2021 who required intubation for 10+ days. Subjects who met criteria were enrolled at an outpatient laryngology clinic, where they underwent a clinical evaluation with head and neck exam, nasolaryngoscopy, and patient-reported outcome measures (Voice Handicap Index, EAT-10). Medical history was collected through electronic medical record review. Result(s): In total, 166 patients met criteria based on chart review. Of these patients, 31 (18.6%) were deceased since discharge. Enrolled subjects included 16 patients, 2 women and 14 men, with mean (SD) age of 57.4 (14.12) years. The mean duration (SD) of IMV was 36.8 (21.8) days. Fourteen of 16 patients underwent tracheostomy for prolonged endotracheal intubation. The mean time (SD) from hospital admission to intubation was 2.7 (3.2) days, intubation to tracheostomy or extubation was 13.9 (5.3) days, and tracheostomy to decannulation was 38.1 (22.6) days. Conclusion(s): Patients who required prolonged mechanical ventilation to treat COVID acute respiratory distress syndrome demonstrated significant laryngeal or tracheal pathology during laryngoscopy at 1-year follow-up, though subjectively, their self-reported voice and swallowing deficits were mild.

8.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P69-P70, 2022.
Article in English | EMBASE | ID: covidwho-2064500

ABSTRACT

Introduction: Early literature describes an array of laryngotracheal complications in patients who were hospitalized with COVID-19. Laryngotracheal stenosis (LTS), in particular, is difficult to manage, requiring multiple procedures, frequent follow-up, and long-term reliance on tracheostomy. We aim to characterize the timeline and challenges associated with surgical management of LTS in this patient population. Method(s): We conducted a retrospective review of patients who presented to laryngology clinic after hospitalization with COVID-19 at a tertiary academic medical center from June 2020 to September 2021. Those who were diagnosed with LTS, intubated during their hospitalization, and underwent surgical management were included. Data on patient demographics, duration of intubation and tracheostomy, access to specialty clinic, and timeline of surgical care were collected. Result(s): A total of 9 patients were identified. Six patients had posterior glottic stenosis (PGS) (67%), 1 had subglottic stenosis (SGS) (11%), and 2 had tracheal stenosis (22%). The median duration of intubation was 21 days (IQR: 15-30). Of the patients, 67% underwent tracheostomy during the study period. Median duration of time between tracheostomy placement and decannulation was 75 days (IQR: 59.5-117). The median duration between COVID-19 diagnosis and presentation to laryngology clinic was 150 days (IQR: 65-209). All 6 patients with PGS underwent at least 1 laser cordotomy procedure. Those with SGS and tracheal stenosis underwent endoscopic procedures, while the latter patients also underwent tracheal resection. The median duration between COVID-19 diagnosis and the first operating room (OR) procedure was 201 days (IQR: 83.5-308.5). The median number of OR procedures per patient was 2 (IQR: 1-3.5). Conclusion(s): LTS after hospitalization with COVID-19 represents a significant challenge for both patients and their providers, often requiring multiple surgeries and delays in tracheostomy decannulation. Studies characterizing surgical management and long-term outcomes in these patients are imperative.

9.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P67, 2022.
Article in English | EMBASE | ID: covidwho-2064480

ABSTRACT

Introduction: Tracheostomy is often performed in patients with a prolonged course of endotracheal intubation to minimize sedation, facilitate ventilator weaning, or to address other clinical complexities. However, the clinical benefit of tracheostomy during severe COVID-19 infection is not fully understood. Method(s): A retrospective single-system, multicenter observational cohort study was performed on patients intubated in the setting of COVID-19 infection in the University of Pennsylvania Health System during 2020 and 2021. Patients who received intubation alone were compared with patients who received intubation and subsequent tracheostomy. Data analyses included patient demographics, comorbidities, and hospital course. Result(s): Of 777 patients, 452 were male (58.2%) and 325 were female (41.8%) with a mean age of 62.2+/-15.4 years. A total of 185 (23.8%) patients underwent tracheostomy, and the mean time from endotracheal intubation to tracheostomy was 17.3+/-9.7 days. Medical comorbidities were associated with undergoing tracheostomy, including immunocompromise (odds ratio [OR]=5.2;P<.0001), current smoker (OR=3.3;P=.0034), cardiovascular disease (OR=2.2;P<.0001), and diabetes mellitus (OR=1.5;P=.0344). Tracheostomy was associated with a significantly longer hospital length of stay (57.5+/-32.2 days vs 19.9+/-18.1 days;P<.0001). However, patients who underwent tracheostomy were significantly less likely to expire during their hospitalization than those who did not undergo tracheostomy (OR=2.79;P<.0001). Conclusion(s): The difference in in-hospital mortality between COVID-19 patients who received intubation and those who received both intubation and tracheostomy suggests an association between tracheostomy and improved outcomes in the setting of severe COVID-19 infection.

10.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P252-P253, 2022.
Article in English | EMBASE | ID: covidwho-2064418

ABSTRACT

Introduction: Viral upper respiratory tract infections (URTI) such as respiratory syncytial virus, rhinoenterovirus coronavirus, and others are common in children, and they can have serious effects on the pediatric airway. The literature is limited on how often ear, nose, and throat (ENT) clinician involvement is required in patients admitted with a URTI. This project aims to characterize and identify factors associated with ENT involvement in care of pediatric patients with positive respiratory virus panels (RVP) and if any require airway interventions. Method(s): A retrospective study was conducted collecting information on patient demographics, comorbidities, course of treatment, incidence of ENT consultation, and incidence of airway interventions (flexible laryngoscopy, intubation, tracheostomy, direct laryngoscopy, etc) for all pediatric patients with a positive RVP who were treated either inpatient or in the emergency department from January 2018 to January 2020 at a tertiary care academic facility. Result(s): A total of 1019 of 1317 consecutive charts with a positive RVP over a 2-year period were reviewed. Preliminary result analysis was completed for the 1019 completed charts. Twenty-eight patients (2.7%) required an ENT consultation. Congenital birth defects were significantly associated with ENT consultation (odds ratio [OR]=3.75;P=.001). Length of stay was significantly associated with higher rate of ENT consultation per day of stay (OR=1.07 per day of stay;P<.001). All other factors studied were not significantly associated with higher rate of ENT consult. Conclusion(s): The incidence of ENT consultation in inpatients with URTIs is relatively uncommon. The preliminary data of this study suggest congenital birth defects and longer length of stay could be used as potential markers to help identify patients who may be at increased risk for worse airway outcomes and need for further airway intervention.

11.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P226, 2022.
Article in English | EMBASE | ID: covidwho-2064405

ABSTRACT

Introduction: Extracorporeal membrane oxygenation (ECMO) can be used during difficult airway surgery because it provides an unobstructed operative field while ensuring adequate oxygenation without need for ventilation. We present a case of utilizing ECMO to perform urgent tracheostomy on a COVIDpositive patient with a large oropharyngeal mass causing critical airway narrowing. Method(s): A 62-year-old man presented with 6 months of worsening dyspnea. Computed tomography imaging and flexible laryngoscopy showed a large oropharyngeal mass extending into the nasopharynx and larynx causing critical airway narrowing and severely distorted upper airway anatomy. Traditional methods to secure the airway including transnasal vs transoral intubation vs awake tracheostomy were considered inadequate due to tumor location/friability, trismus, inability to lie flat, and unclear tracheal landmarks on palpation. In addition, on the day of surgery, the patient tested positive for COVID. We decided ECMO was the safest method to safely perform tracheostomy while minimizing COVID aerosolization. Result(s): The thoracic surgery team proceeded with bifemoral cannulation, and ECMO was initiated in less than 30 minutes. Standard tracheostomy was performed, and biopsies of the oropharyngeal mass were obtained. The patient was weaned off ECMO after <1 hour and awakened without any issues. There were no complications from bi-femoral venous access. Conclusion(s): Multiple methods to secure this patient's difficult airway were considered. Fiber-optic nasal intubation would require navigating the bronchoscope around the large tumor partially obstructing the nasopharynx and larynx. Awake tracheostomy was considered risky due to his large neck circumference, significant coughing episodes, and inability to lay supine. Both of these options would also be associated with high levels of COVID aerosolization. The use of ECMO allowed for apneic tracheostomy while minimizing the risk of COVID infection to all operating room personnel. In the era of COVID, ECMO is an unconventional but powerful tool that should be added to the armamentarium of highrisk airway surgery.

12.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P228, 2022.
Article in English | EMBASE | ID: covidwho-2064403

ABSTRACT

Introduction: Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries, and there is an increasing need for intubation and mechanical ventilation currently due to the COVID-19 pandemic. It is important to fill the literature gaps regarding the incidence of laryngeal injury following prolonged intubation due to COVID-19. Method(s): This study is a retrospective review of patients with swallowing, voice, or airway concerns identified by their primary physician or speech-language pathologist who were evaluated using flexible laryngoscopy from August 14, 2020, to August 18, 2021. A total of 25 patients with COVID-19 and 27 patients without COVID-19 were included. Specific injuries evaluated for were edema/erythema, granulation tissue/ ulceration, posterior glottic stenosis, subglottic stenosis, vocal cord immobility, and vocal cord paralysis. Severe lesions were those that caused significant airway obstruction or required operative treatment or tracheostomy dependence. Result(s): Within the COVID-19 group, 80% of patients had laryngeal injury, with 45% of these in the severe category. In the non-COVID-19 group, 62.9% of patients had a laryngeal injury, with 23.5% being severe. Mild injuries were seen in 44% of COVID-19 patients and 48% of non-COVID-19 patients. The most common injury category seen was granulation tissue/ulceration. Patients with severe injuries were intubated for 6 to 39 days (mean 14.8), those with mild injuries were intubated for 0 to 31 days (mean 10.4), and patients with no injuries were intubated for 0 to 34 days (mean 9.53). Conclusion(s): Patients who were intubated for COVID-19 were more likely to have severe clinically significant laryngeal injuries than non-COVID-19 patients, even when they were intubated for similar amounts of time. Interestingly, the incidence of mild injuries was similar between the 2 groups. Based on these results, it may be beneficial to have a lower threshold for performing flexible laryngoscopy on postintubated COVID-19 patients to evaluate for laryngeal injury. This would allow for earlier intervention and, it is hoped, reduction of morbidity.

13.
J Cardiothorac Vasc Anesth ; 2022 Sep 20.
Article in English | MEDLINE | ID: covidwho-2062301

ABSTRACT

OBJECTIVES: Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO. DESIGN: A Retrospective review of electronic data for routine care of patients on ECMO. SETTING: Tertiary, university-affiliated national ECMO center. PARTICIPANTS: Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support. INTERVENTIONS: No intervention was conducted during this study. MEASUREMENTS AND MAIN RESULTS: Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection. CONCLUSIONS: In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.

14.
J Laryngol Otol ; : 1-10, 2022 Oct 11.
Article in English | MEDLINE | ID: covidwho-2062087

ABSTRACT

BACKGROUND: Coronavirus disease 2019 increased the numbers of patients requiring prolonged mechanical ventilation, with a subsequent increase in tracheostomy procedures. Coronavirus disease 2019 patients are high risk for surgical complications. This review examines open surgical and percutaneous tracheostomy complications in coronavirus disease 2019 patients. METHODS: Medline and Embase databases were searched (November 2021), and the abstracts of relevant articles were screened. Data were collected regarding tracheostomy technique and complications. Complication rates were compared between percutaneous and open surgical tracheostomy. RESULTS: Percutaneous tracheostomy was higher risk for bleeding, pneumothorax and false passage. Surgical tracheostomy was higher risk for peri-operative hypoxia. The most common complication for both techniques was post-operative bleeding. CONCLUSION: Coronavirus disease 2019 patients undergoing tracheostomy are at higher risk of bleeding and peri-operative hypoxia than non-coronavirus disease patients. High doses of anti-coagulants may partially explain this. Reasons for higher bleeding risk in percutaneous over open surgical technique remain unclear. Further research is required to determine the causes of differences found and to establish mitigating strategies.

15.
Chest ; 162(4):A2681, 2022.
Article in English | EMBASE | ID: covidwho-2060982

ABSTRACT

SESSION TITLE: Late Breaking Investigations From Pulmonary and Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Critical care patients receive over 50% of gastrostomy tubes placed in the United States. Studies support performing concomitant tracheostomy and gastrostomy to improve efficiencies in care and reduce healthcare costs. Prior research has supported the safe performance of Percutaneous Ultrasound Gastrostomy (PUG) by interventional radiologists. Our recent study, Length of Stay and Hospital Cost Reductions After Implementing Bedside Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit, demonstrated that PUG placement by ICU physicians in patients with ventilator-dependent respiratory failure significantly reduced ICULOS and hospital LOS by 5 and 8 days respectively, and total hospital costs by $26,621 per patient. 70% of PUG procedures were performed concomitantly with tracheostomy (TPUG), compared to 0 in the usual care gastrostomy group. We now report a post hoc safety analysis assessing adverse events and patient comorbidity between these groups. METHODS: Post hoc analysis was performed on a retrospective cohort of patients with ventilator-dependent respiratory failure, grouped by those who received a gastrostomy consultation with gastroenterology or interventional radiology (usual care) and those who received a bedside PUG by a critical care physician. Adverse events related to gastrostomy placement were compared between groups using Fisher’s Exact tests. Charlson Scores were calculated for each patient and compared, as well as for the subgroup of patients with adverse events, using Student’s t-tests. RESULTS: There were 43 patients in the usual care group and 45 in the PUG group. Adverse events (AEs) in the usual care group totaled 16;7 major and 9 minor. AEs in the PUG group totaled 13;5 major and 8 minor. There were no significant differences between groups related to AEs (p=0.498). 28 of the usual care patients and 31 of the PUG patients were COVID-19 positive, respectively (p=0.71). The usual care and PUG groups had average Charlson scores of 2.88 (SD 2.13) and 3.23 (SD 2.32), respectively (p=0.537). The subgroup of patients with complications in each group had statistically equivalent Charlson scores (p=0.624). CONCLUSIONS: Our analysis demonstrates no difference in adverse events between PUG and usual care. PUG may be safely performed by Critical Care physicians at the bedside and in combination with tracheostomy. Performing PUG as the initial gastrostomy option in ventilatory-dependent patients decreases LOS and total hospital costs, without negatively affecting procedural adverse events. CLINICAL IMPLICATIONS: This research supports PUG as a safe method of gastrostomy placement by Critical Care physicians which may be performed at the bedside concomitantly to tracheostomy, driving reductions in ICULOS, hospital LOS, and total hospital costs per patient, with no significant increase in adverse events. DISCLOSURES: No relevant relationships by Jason Heavner No relevant relationships by Jeffrey Marshall No relevant relationships by Peter Olivieri No relevant relationships by Janelle Thomas No relevant relationships by Hannah Van Ryzin No relevant relationships by R. Gentry Wilkerson

16.
Chest ; 162(4 Supplement):A2650-A2651, 2022.
Article in English | EMBASE | ID: covidwho-2060977

ABSTRACT

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The Galaxy SystemTM (Noah Medical, San Carlos, CA) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct CT-to-body divergence and novel confirmation of tool-in-lesion. The primary aim of this study was to assess the tool-in-lesion accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHOD(S): Over four separate days, four operators (the authors) conducted the experiment using four pigs. Each physician performed between 4 and 6 nodule biopsies for 20 lung nodule biopsies. A porcine model (S. s. domesticus) was utilized. Each pig was anesthetized with volatile gas and underwent tracheostomy with an 8.5 endotracheal tube and bilateral chest tube thoracostomy. Anesthesia was monitored by a veterinarian with invasive hemodynamic monitoring. Under CT fluoroscopic guidance, simulated lung nodules were created by percutaneous injection of a gelatinous agar solution containing purple dye and radiopaque material into the lung periphery. A CT was then performed for pre-procedure planning. Using Galaxy's "Tool in Lesion TOMO+" with augmented fluoroscopy, the physician navigated to the lung nodules and a tool (needle) was placed into the lesion. Tool in lesion was defined by the needle in or tangential to the lesion determined by CBCT. Center strike was defined as the needle in the middle third in three orthogonal angles (axial, sagittal, and coronal) on CBCT. RESULT(S): Lung nodules' average size was 16.3+/-0.97 mm and were predominantly in the lower lobes (65%). Only 15% (3/20) had a bronchus sign and the average distance to the pleura was 6.88+/-5.5 mm. All four operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). Tool in lesion after final tomography sweep was 100% (20/20). Biopsy yielding purple pigmentation on microscopic or gross examination was also 100% (20/20). Center strike rate was 60%. CONCLUSION(S): The Galaxy SystemTM demonstrated successful digital tomography confirmed tool in lesion success in 100% (20/20) of lesions as confirmed by CBCT. Successful biopsy was achieved in 100% of lesions as confirmed by intralesional pigment acquisition. CLINICAL IMPLICATIONS: The combination of robotic navigation, catheter maneuverability and real-time correction for CT body divergence capitalizes on the strengths of all three technologies to improve diagnosis. Additional clinical trials are warranted to see if high success rates can be reproduced in patients. DISCLOSURES: Consultant relationship with Medtronic ILS Please note: $20001 - $100000 by Krish Bhadra, value=Consulting fee Consultant relationship with Veractye Please note: $1-$1000 by Krish Bhadra, value=Consulting fee Consultant relationship with Bodyvision Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Merit Endotek Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Human Factor Testing relationship with Auris Surgical Robotics Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Intuitive Surgical Robotics Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Biodesix Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Noah Medical Please note: 5/2020 Added 06/01/2022 by Krish Bhadra, value=Consulting fee Speaker relationship with Body Vision Please note: 2015 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Magnisity Please note: 2021 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Auris (J&J Ethicon) Please note: 2014-present Added 05/29/2022 by Douglas Hogarth, value=Honoraria Consultant relationship with Boston Scientific Please note: 2008 - present Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Please note: 2010-2019 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Broncus Please note: 2017-2021 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with PulmonX Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Spiration Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Eolo Please note: $20001 - $100000 by Douglas Hogarth, value=Ownership interest Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Boston Scientific Corporation Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Pulmonx Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Ambu USA Please note: $1-$1000 by Amit Mahajan, value=Consulting fee Consultant relationship with Circulogene Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Medtronic/Covidien Please note: $1001 - $5000 by Otis Rickman, value=Consulting fee Copyright © 2022 American College of Chest Physicians

17.
Chest ; 162(4):A2099, 2022.
Article in English | EMBASE | ID: covidwho-2060898

ABSTRACT

SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Recent advances in the management of airway disorders have provided additional therapeutic options for pathology, such as central airway obstruction (CAO). Symptomatic CAO has been managed by bronchoscopic interventions with a high risk of airway compromise and respiratory failure. Other alternatives such as mechanical and jet ventilation may not ensure adequate respiratory support during the procedure and cause delays in life-saving treatments. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used as an adjunct to preserve safety during these airway interventions [1,2]. We present a case of complete tracheal occlusion successfully intervened using VV ECMO support. CASE PRESENTATION: The patient is a 55-year-old male with a history of ventilator-dependent respiratory failure s/p tracheostomy, secondary to post COVID-19 fibrosis, who presented from a long-term acute care facility with worsening hypoxemia. The patient was transferred to the intensive care unit, where he underwent flexible bronchoscopy via the tracheostomy lumen, which did not reveal a patent airway. Orotracheal intubation was unsuccessful as there was complete occlusion of the airway below the vocal cords with abundant granulation tissue. Interventional pulmonology was consulted, and emergent recanalization of the airway with rigid bronchoscopy-mediated debulking was performed. Due to the severity of hypoxemia, cardiothoracic surgery was consulted, and the patient was placed on VV ECMO to support further intervention. The patient was intubated with EFER-DUMON 13 mm rigid bronchoscope. Complete recanalization was achieved using a rigid barrel and forceps with patency of both mainstems and all segmental bronchi. There were no postprocedural complications, and the patient returned to his baseline ventilator settings. DISCUSSION: VV ECMO has been used as an adjunct to preserve safety during high-risk bronchoscopic interventions, primarily in CAO. Acute respiratory decompensation remains a feared complication during these interventions in cases of CAO. Initiating ECMO before these interventions may reduce the incidence of respiratory failure and airway compromise. In a case series, ECMO has been described by Stokes et al. as a supportive measure facilitating such interventions [3]. Further guidelines are required to standardize ECMO initiation as procedural support during airway interventions. CONCLUSIONS: Planned preprocedural ECMO initiation can prevent respiratory emergencies and allow therapeutic high-risk airway interventions. The choices for this patient were stark- either airway recanalization without ECMO bridge with a risk of hypoxic brain injury vs. VV ECMO support and curative airway intervention. In the absence of large-scale data and based on local availability of excellent ECMO support and Interventional Pulmonology, the latter approach was used, leading to successful and safe airway recanalization. Reference #1: Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A et al.Venovenous bypass with a membrane lung to support bilateral lung lavage. JAMA 1984;251:3269–71. Reference #2: Fung R, Stellios J, Bannon PG, Ananda A, Forrest P. Elective use of venovenous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Anaesth Intensive Care 2017;45:88–91. Reference #3: Stokes JW, Katsis JM, Gannon WD, Rice TW, Lentz RJ, Rickman OB, Avasarala SK, Benson C, Bacchetta M, Maldonado F. Venovenous extracorporeal membrane oxygenation during high-risk airway interventions. Interact Cardiovasc Thorac Surg. 2021 Nov 22;33(6):913-920. doi: 10.1093/icvts/ivab195. PMID: 34293146;PMCID: PMC8632782 DISCLOSURES: No relevant relationships by Vatsal Khanna No relevant relationships by Anurag Mehrotra No relevant relationships by Trishya Reddy No relevant relationships by Bernadette Schmidt

18.
Chest ; 162(4 Supplement):A1586-A1587, 2022.
Article in English | EMBASE | ID: covidwho-2060846

ABSTRACT

SESSION TITLE: Technological Innovations in Imaging SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 PM - 2:30 PM PURPOSE: Central airway stenosis (CAS) is an important cause of pulmonary morbidity and mortality. Current grading and classification systems include subjective qualitative components, with limited data on reproducibility. We propose a novel radiographic segmentation approach to more objectively quantify CAS. Inter-rater reliability of this novel outcome, which is used in an ongoing randomized controlled trial (NCT04996173), has not been previously assessed. METHOD(S): Computed tomography (CT) scans demonstrating tracheal stenoses were identified in the Vanderbilt University Medical Center Benign Tracheal Stenosis registry. CTs were analyzed in OsiriX (Geneva, Switzerland) after upload via a secured cloud transfer service. Four independent readers with variable experience in CT interpretation were chosen (one chest radiologist, one pulmonary fellow, two internal medicine residents). Readers identified the point of nadir airway lumen, measured 1.5 cm above and below that point, then manually segmented visible tracheal lumen area on the soft tissue window of each axial CT slice within that 3 cm length. Missing ROI's were then generated in-between manual segmented areas. The Repulsor function was used to manually adjust the boundaries of the ROI to achieve fit. Intraclass correlation (ICC) was used to calculate the inter-rater reliability of the tracheal lumen volume of between readers. Other data collection variables included the type of CT scan, axial slice interval, the suspected underlying cause of CAS, and average stenotic volume. RESULT(S): Fifty CT scans from 38 individual patients identified in the registry from 2011-2021 were randomly chosen for inclusion. Most (22 of 38, 57.9%) had iatrogenic BCAS (either post-intubation or post-tracheostomy) and 10 (26.3%) had idiopathic subglottic stenosis. Half of the scans (n=25, 50%) were contrasted neck CT and half were non contrasted chest CTs. Scan slice thickness ranged 1 to 5 mm, median 2 mm (1.25-2.875). The median stenotic volume across all readers was 3.375 cm3 (2.52-4.51). The average ICC across all four readers was 0.969 (95% CI 0.944 - 0.982). CONCLUSION(S): Our proposed volume rendering and segmentation approach to BCAS proves to have substantial precision and agreement amongst readers of different skill levels. CLINICAL IMPLICATIONS: A NOVEL METHOD TO ASSESS SEVERITY OF BENIGN CENTRAL AIRWAY STENOSIS DISCLOSURES: No relevant relationships by Leah Brown No relevant relationships by Alexander Gelbard no disclosure on file for Robert Lentz;PI ofan investigator-initiated study relationship with Medtronic Please note: >$100000 by Fabien Maldonado, value=Grant/Research Support PI on investigator-initiated relationship with Erbe Please note: $5001 - $20000 by Fabien Maldonado, value=Grant/Research Support Consulting relationship with Medtronic Please note: $5001 - $20000 by Fabien Maldonado, value=Honoraria co-I industry-sponsored trial relationship with Lung Therapeutics Please note: $5001 - $20000 by Fabien Maldonado, value=Grant/Research Support Board of director member relationship with AABIP Please note: $1-$1000 by Fabien Maldonado, value=Travel No relevant relationships by Khushbu Patel No relevant relationships by Ankush Ratwani Consultant relationship with Medtronic/Covidien Please note: $1001 - $5000 by Otis Rickman, value=Consulting fee No relevant relationships by Evan Schwartz Copyright © 2022 American College of Chest Physicians

19.
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

20.
Chest ; 162(4):A1393-A1394, 2022.
Article in English | EMBASE | ID: covidwho-2060813

ABSTRACT

SESSION TITLE: Invasion of the Pleura SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Schwannoma is a well circumscribed encapsulated solitary neoplasm arising from myelin producing cells of peripheral nerve sheaths. Pleural schwannomas represent only 1-2% of thoracic tumors and rarely present with pleural effusion. To our knowledge only six cases of benign pleural schwannoma have presented with a pleural effusion to date. We present a rare case of a pleural schwannoma with bilateral serosanguinous pleural effusions complicated by necrotizing pneumonia. CASE PRESENTATION: 54 year old smoking male with no past medical history was transferred from an outside hospital after two weeks of worsening acute hypoxemic respiratory failure while being treated for necrotizing pneumonia, right sided loculated pleural effusion, and a right paramediastinal mass. His only presenting symptom was worsening dyspnea for three days. Upon arrival to our hospital, the patient was on maximal ventilator settings with two right sided chest tubes draining blood tinged pleural fluid. CTA of the chest showed a large cavitary consolidation in the right upper lobe with destruction of the lung parenchyma. Additionally, there was an intrapleural heterogenous mass in the posterior aspect of the right lung apex which abut the mediastinum measuring 9.7 x 7.5 x 10.3 cm. He was treated with zosyn for positive sputum cultures growing beta hemolytic strep group F. Patient underwent a flexible bronchoscopy with EBUS-TBNA of mediastinal lymphnodes and lung mass which was non-diagnostic. A CT guided biopsy revealed a spindle cell neoplasm with a Ki-67 of 10-20%. Immunohistochemical analysis demonstrated positive staining of the tumor cells for S-100 protein. The final pathological diagnosis was benign schwannoma. He underwent a tracheostomy and PEG and was sent to a rehab center with outpatient follow-up with cardiothoracic surgery for tumor removal. DISCUSSION: Pleural schwannomas are slow growing, rarely progress to malignancy, and are often located in the posterior mediastinum. Patients are usually asymptomatic but can present with symptoms associated with obstructive pneumonia. It is very rare for a benign pleural schwannoma to present with a pleural effusion. Literature review has revealed only six cases of benign schwannoma presenting with a pleural effusion, all of which were blood stained. Spontaneous tumor hemorrhage or cyst rupture has been a theory of etiology for the effusions. Prognostically, once the pleural schwannomas are surgically resected there is minimal chance of recurrence. CONCLUSIONS: Our case represents a benign pleural schwannoma that caused extrinsic compression on the right upper lobe bronchus leading to a necrotizing pneumonia along with bilateral serosanguinous pleural effusions. A pleural schwannoma should be considered in the differential diagnosis of intrathoracic tumors even when presenting with pleural effusions. Reference #1: Shoaib D, Zahir M, Khan S, et al. Difficulty Breathing or Just a Case of the Nerves? Incidental Finding of Primary Pleural Schwannoma in a Covid-19 Survivor. Cureus. 2021. 13(8): e17511. Reference #2: Bibby A, Daly R, Internullo E, et al. Benign Pleural Schwannoma Presenting with a Large, Blood Stained Pleural Effusion. Thorax. 2018. 73:497-498. Reference #3: Nosrati R, Annissian D, Ramezani F, et al. Benign schwannoma of posterior mediastinum accompanied by blood pleural effusion misdiagnosed as solitary fibrous tumor: A Case report. Casplan J Intern Med. 2019. 10:468-471. DISCLOSURES: No relevant relationships by Brittany Bass No relevant relationships by Oleg Epelbaum No relevant relationships by Theresa Henson No relevant relationships by Yasmin Leigh No relevant relationships by Ester Sherman No relevant relationships by Sally Ziatabar

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