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The COVID-19 pandemic has impacted every aspect of our lives since its start in December 2019. Among various COVID-19 complications, pleural complications are also increasingly reported but rarely from Nepal. Here, we presented a case of pyopneumothorax in a 52-year-old male patient referred from another center and admitted to the ICU of Nepal Armed Police Force Hospital with a diagnosis of severe COVID-19 pneumonia in the background of alcohol withdrawal syndrome with delirium tremens and generalized tonic-clonic seizures. He developed a rapid decline in respiratory status with a right-sided pneumothorax and underwent an immediate needle thoracostomy, followed by chest tube insertion. On the sixth day of admission, he had thick yellowish pus in the chest drain (pyopneumothorax), and despite the rigorous efforts in treatment, he died on the 15th day of admission. Though relatively uncommon, clinicians should consider pleural complications like pneumothorax, pleural effusion, pneumomediastinum, and empyema in patients with impaired immune status. In such patients, we should ensure prompt diagnosis with the earliest intervention and rationale use of antibiotics.
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Background: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) is an extremely infectious virus causing COVID-19 illness. Respiratory failure is a consequence of COVID-19 illness related pneumonia, in which mechanical ventilation and endotracheal intubation are essential. Barotrauma is a chief complication due to mechanical ventilation, in which pneumothorax was established in 25% of COVID-19 barotrauma patients. The majority of complicated COVID-19 cases with a pleural effusion or pneumothorax require a thoracostomy. Objective: To recognize and analyse tube thoracostomy consequences in COVID-19 complicated individuals through this pandemic. Patients and Methods: A retrospective study was accomplished in Thoracic Surgery Unit of Elkasr Elaini Medical Center, Cardiothoracic Surgery Department in Cairo University, Cairo, Egypt. We included fifteen COVID-19 individuals entered the ICU in the period between June 2020 and September 2021 requiring thoracic surgery consultation. Non-COVID-19 severe illness and iatrogenic pneumothorax were omitted from this study. Results: Nine pneumothorax cases (73.3%), two surgical emphysema associated with pneumothorax cases (13.3%), three pleural effusion cases (20%) and one hydropneumothorax case (6.7%) as a total of fifteen patients needed thoracic surgery consultation. After tube thoracostomy, there were no harm consequences. From the total number of patients, 12 well improved and discharged (80%) and three were dead (20%) within three days after tube thoracostomy who were mechanically ventilated due to respiratory failure after ARDS. Conclusion: COVID-19 complicated cases needed chest tube insertion is associated with good outcomes and improvement. © 2022, Ain Shams University Faculty of Medicine. All rights reserved.
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INTRODUCTION: The first data for COVID-19 in pregnancy showed mild-to-moderate forms of the disease while the current data speak of severe forms in these subjects. Here, we present a case of a severe form of COVID-19 in a gemelar pregnant woman complicated with pneumomediastinum and pneumothorax, during her hospital stay, in a late stage of disease. CASE PRESENTATION: A 38-year-old multiparous woman was referred to university hospital at 25 weeks of gemelar pregnancy. On admission, the patient presented with signs of moderate respiratory insufficiency, which after 12 h progressed further to severe ARDS. She tested positive for SARS-CoV-2 on quantitative real-time polymerase chain reaction. Under these conditions, it was decided that the patient undergoes a cesarean section for termination of pregnancy. Remdesivir 200 mg/day and tocilizumab 8 mg/kg were administered, based on national guidelines. The patient’s fever subsided, but her SpO2 remained at 94%, even with a 15 L/min oxygen mask. After 12 days, the patient complains of a severe back pain and her respiratory condition rapidly worsened and reduced saturations up to 80% being under O2 therapy with facial mask with 15 l/min. Chest CT findings confirmed pneumomediastinum and pneumothorax, which deteriorated the patient’s status. Thereafter, tube thoracostomy was performed. There was a clinical and ABG analysis parameter’s improvement. The patient was discharged 34 days after cesarean delivery with a proper general health. CONCLUSION: Our case highlights even more convincingly the fact that, in pregnancy, can be severe to life-threating forms of COVID-19. Pneumothorax and pneumomediastinum are complications that can be encountered even in the late stages of severe forms cases with COVID-19 in pregnancy. Early diagnosis of these complications is essential in adequate management and treatment to avoid fatal outcome.
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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: One of the greatest challenges of the coronavirus (COVID-19) pandemic has been deciphering its unique properties, such as the propensity to infect and damage lung epithelium, thereby increasing susceptibility to pulmonary complications.(1, 2) A 2020 cohort study comparing patients with acute respiratory distress syndrome (ARDS) from COVID-19 and ARDS from other causes showed a significantly higher rate of subcutaneous emphysema and pneumomediastinum in the COVID-19 group, suggesting these diagnoses may be due to direct viral damage rather than exposure to positive pressure alone.(3) Presented here is a patient with no underlying lung pathology who was diagnosed with COVID-19 and developed severe subcutaneous emphysema, pneumomediastinum, and pneumothorax. CASE PRESENTATION: A 74 year old male with a history of hypertension presented to the emergency room with a 5-day history of difficulty breathing, cough, fever, chills, and weakness. He tested positive for COVID-19, required non-invasive positive pressure ventilation (NIPPV), and was started on ceftriaxone, doxycycline, and daily dexamethasone. He received a five-day course of remdesivir and one dose of convalescent plasma. By day 9, a chest x-ray revealed a left apical pneumothorax, bilateral subcutaneous emphysema, and pneumomediastinum. On day 12, his respiratory status deteriorated, necessitating invasive mechanical ventilation. A chest CT showed extensive subcutaneous emphysema involving the chest, supraclavicular and axillary regions, and abdominal wall, as well as extensive pneumomediastinum and a moderate left pneumothorax. A left-sided thoracostomy tube was placed and he was proned per ICU protocol. He required placement of a second left-sided chest tube due to persistent worsening pneumothorax. On day 28, despite all aggressive measures, he expired from acute hypoxemia. DISCUSSION: Although this patient was exposed to NIPPV, the severe degree of lung pathology was inconsistent with the amount of positive pressure administered. Furthermore, he lacked underlying pulmonary disease that would compromise his lung compliance to this magnitude. Combining evidence that COVID-19 can cause epithelial lung damage, the patient's absence of pulmonary risk factors, and his severe degree of lung damage incongruent with his exposure to positive pressure, is reasonable to extrapolate that a significant portion of his lung pathology was a result of direct damage from COVID-19. CONCLUSIONS: Patients with COVID-19 may be at higher risk for the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax, likely due to direct viral effect. Lung damage seen may be disproportionate to exposure of positive pressure and may also be seen in the absence of any underlying pulmonary comorbidities. Awareness of this observed pathophysiology may help guide clinicians to optimize ventilator management as well as anticipate potential complications. Reference #1: Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and COVID-19 [published correction appears in Nat Rev Microbiol. 2022 Feb 23;:]. Nat Rev Microbiol. 2021;19(3):141-154. doi:10.1038/s41579-020-00459-7 Reference #2: Miró Ò, Llorens P, Jiménez S, et al. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study. Chest. 2021;159(3):1241-1255. doi:10.1016/j.chest.2020.11.013 Reference #3: Lemmers DHL, Abu Hilal M, Bnà C, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?. ERJ Open Res. 2020;6(4):00385-2020. Published 2020 Nov 16. doi:10.1183/23120541.00385-2020 DISCLOSURES: No relevant relationships by Shanaz Azad No relevant relationships by Sarah Monaghan No relevant relationships by Brandon Nance No relevant relationships by Samantha Peterson
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SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Human cytomegalovirus (CMV) is a herpesvirus with a high prevalence that causes latent disease in immunocompetent hosts. It is an important opportunistic infection with a variety of clinical manifestations, including pneumonia, in immunocompromised patients.[1] CASE PRESENTATION: A 45-year-old man with no past medical history presented with fever and dyspnea and was positive for coronavirus disease 2019 (COVID-19). He developed acute respiratory distress syndrome (ARDS) and was intubated 13 days after presentation, but developed refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation (ECMO) (cannulated 16 days after presentation). He received a 5-day course of remdesivir and 10 days of dexamethasone 6 mg daily. His course was complicated by acute renal failure requiring continuous renal replacement therapy, septic shock due to a pseudomonal ventilator-associated pneumonia, right ventricular failure, heparin induced thrombocytopenia, and right pneumothorax requiring chest tube thoracostomy. After 4 weeks of ECMO there was lung recovery with ECMO sweep gases <1L/minute, improved radiographic appearance and tidal volumes, and decannulation was anticipated. However, he subsequently developed profound shock of unknown etiology with a rapid worsening of his lung function requiring increased ECMO support. Care was withdrawn at ECMO day 46 due to multiorgan failure. Pathology of his lungs at autopsy showed prominent intranuclear viral inclusions and positive immunohistochemistry in alveolar macrophages consistent with a diagnosis of CMV pneumonia. DISCUSSION: While CMV typically causes latent disease it can reactivate in the setting of immunosuppression and/or critical illness.[1] Patients with severe COVID-19 frequently are treated with immunosuppressive therapies, such as corticosteroids, anti-interluekin-6 therapies, and JAK inhibitors. Due to this immunosuppression, opportunistic infections have been reported in these patients.[2] It can be difficult to differentiate COVID-19 pneumonia from other respiratory infections based on imaging and lab studies alone, especially in patients with prolonged mechanical ventilation and with severe parenchymal disease requiring ECMO support. Little is known about the incidence of CMV and COVID-19 coinfection. There are several cases of biopsy-proven CMV pneumonia in immunocompromised critically ill patients with COVID-19, but this is the first reported case in an immunocompetent patient. CONCLUSIONS: This case highlights the need to maintain a high degree of suspicion for CMV pneumonia in patients with severe COVID-19 pneumonia who receive immunosuppressive therapies. While the diagnosis was made at autopsy in this case, it may be possible to arrive at an earlier diagnosis with CMV polymerase chain reaction (PCR) assays sent from the serum and bronchoalveolar lavage (as lung biopsies are usually impractical in ARDS). Reference #1: de la Hoz RE, Stephens G, Sherlock C. Diagnosis and treatment approaches of CMV infections in adult patients. J Clin Virol. 2002 Aug;25 Suppl 2:S1-12. doi: 10.1016/s1386-6532(02)00091-4. PMID: 12361752. Reference #2: Abdoli A, Falahi S, Kenarkoohi A. COVID-19-associated opportunistic infections: a snapshot on the current reports [published online ahead of print, 2021 Aug 23]. Clin Exp Med. 2021;1-20. doi:10.1007/s10238-021-00751-7 DISCLOSURES: No relevant relationships by Nancy Law No relevant relationships by Mazen Odish No relevant relationships by Robert Owens No relevant relationships by Travis Pollema No relevant relationships by Alyssa Self No relevant relationships by Cassia yi
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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
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SESSION TITLE: Obstructive Lung Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION: 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1: Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https://doi.org/10.4103/ijri.IJRI_340_18 Reference #2: Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https://doi.org/10.1155/2012/242579 Reference #3: Subcutaneous Emphysema in Acute Asthma: A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI: 10.4187/respcare.03750 DISCLOSURES: No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez
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SESSION TITLE: Problems in the Pleura Case Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hematologic malignancies can often be complicated by pleural effusion due to leukemic infiltration of the pleura (1). Long term management of resulting chronic plural effusion can be complicated when there is evidence of trapped lung. Subsequent infection may lead to development of chronic empyema which can be difficult to manage in chronically ill patients (2). CASE PRESENTATION: A 65-year-old male with history of chronic myeloid leukemia status post stem cell transplant was admitted with dyspnea and cough. Computed tomography (CT) chest imaging revealed increased volume loss on the left with new air fluid level in a chronic left pleural effusion. (Image 1) Patient's history was significant for chronic left pleural effusion, which was first identified in 2015 and found to be a malignant effusion with evidence of leukemia involvement. Repeat imaging in 2018 (Image 2) revealed continued chronic pleural effusion. Patient was admitted in August 2021 with COVID-19 pneumonia and CT Chest showed chronic loculated left sided pleural effusion. Patient elected to continue to monitor the chronic effusion, which was completed as outpatient every 4 to 6 weeks (Image 3). He remained clinically stable until the presentation to a hospital in January 2022. The chronic empyema was initially managed with tube thoracostomy, intrapleural fibrinolytics and antibiotics. Cultures were significant for Moraxella catarrhalis and Streptococcus pneumoniae. He was determined to be a poor surgical candidate for decortication and treatment with empyema tube was initiated. The empyema tube was incrementally withdrawn as an outpatient and subsequently removed with good clinical recovery. DISCUSSION: Chronic empyema is characterized by thickened parietal and visceral pleura which limits the ability of the lung to re-expand. Surgical management with decortication is the definitive management, however, in poor surgical candidates, management becomes more complicated. Open pleural drainage with an open pleural window can be considered. An alternative option converts tube thoracostomy to open pleural drainage, as was utilized in this patient (2). While comparison of surgical vs non-surgical management of empyema suggests similar mortality (3), non-surgical management of chronic empyema needs more investigation to determine the optimal treatment modality. CONCLUSIONS: Empyema remains a difficult condition to manage. Treatment modalities of chronic empyema are limited in those patients who remain poor surgical candidates. Reference #1: Faiz SA, Sahay S, Jimenez CA. Pleural effusions in acute and chronic leukemia and myelodysplastic syndrome. Curr Opin Pulm Med. 2014 Jul;20(4):340-6. Reference #2: Biswas A, Jantz MA, Penley AM, Mehta HJ. Management of chronic empyema with unexpandable lung in poor surgical risk patients using an empyema tube. Lung India. 2016;33(3):267-271. Reference #3: Redden MD, Chin TY, van Driel ML. Surgical versus non-surgical management for pleural empyema. Cochrane Database Syst Rev. 2017;3(3):CD010651. Published 2017 Mar 17. DISCLOSURES: No relevant relationships by Shannon Burke No relevant relationships by Abigail Go No relevant relationships by Jen Minoff no disclosure on file for Ravi Nayak;
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SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pneumopericardium is the presence of air or gas in the pericardial space, usually secondary to blunt or penetrating trauma. Most pneumopericardium are non-tension. The use of positive pressure ventilation (PPV) increases the chances of developing a tension pneumopericardium. We report the case of a 22-year-old male patient admitted for COVID-19 pneumonia who developed pneumopericardium with cardiac tamponade features. CASE PRESENTATION: A 22-year-old male was admitted for acute respiratory distress syndrome due to COVID-19 pneumonia and required intubation on hospital day 10. The next day, he became febrile with new leukocytosis. A chest x-ray showed new extensive pneumomediastinum and pneumopericardium. Vasopressor support and broad-spectrum antibiotics were started for septic shock, however he continued to decompensate rapidly, requiring maximal medical support. His arterial line waveform showed pulsus paradoxus, leading to concern for underlying tension pneumopericardium. Bedside echo was unrevealing as imaging was obstructed by the air in pericardial sac. The patient was too unstable for a CT scan of the chest. After extensive discussion with his family, he was placed on palliative measures only and expired. DISCUSSION: Pneumopericardium is due to an abnormal connection between the pericardial space and a source of air or gas. Levin and Macklin describe three main mechanisms by which this connection can be made. The first: acute rises in alveolar pressure and volume or ventilator associated lung injury leading to rupture of alveoli with gas tracking along perivascular and peri bronchial sheaths to the mediastinum. The second: macro-perforation of the pericardial space leading to communication with respiratory or gastrointestinal tracts. Third: existence of a pneumothorax in the presence of traumatic pericardial tear or congenital pleuro-pericardial connection. Spontaneous pneumopericardium without any anatomic connection is rare and is due to a direct extension of infectious etiologies of the lungs or by an infection of the pericardial space with gas forming bacteria. A tension pneumopericardium causing cardiac tamponade can develop from pneumopericardium with PPV where the pericardial sac acts as a shutter valve letting air in but not out as has been reported sparingly in the literature. Cummings et al described 93 patients who developed tamponade out of 252 patients with pneumopericardium. Our patient possibly developed a pleuro-pericardial tract secondary to his pneumonia. With continued PPV his simple pneumopericardium likely developed into a tension pneumopericardium evidenced by arterial waveforms consistent with pulsus paradoxus, worsening hypotension despite maximal vasopressor support and development of ventricular tachycardia. CONCLUSIONS: Our case highlights the importance of considering pneumopericardium causing cardiac tamponade in the setting of mechanical ventilation. Reference #1: Mindaye ET, Arayia A, Tufa TH, Bekele M. Iatrogenic pneumopericardium after tube thoracostomy: A case report. Vol. 76, International journal of surgery case reports. 2020. p. 259–62. Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984 Jun;37(6):511–8. Reference #3: Levin AI, Visser F, Mattheyse F, Coetzee A. Tension pneumopericardium during positive-pressure ventilation leading to cardiac arrest. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):879–82. MACKLIN CC. TRANSPORT OF AIR ALONG SHEATHS OF PULMONIC BLOOD VESSELS FROM ALVEOLI TO MEDIASTINUM: CLINICAL IMPLICATIONS. Arch Intern Med [Internet]. 1939 Nov 1;64(5):913–26. Available from: https://doi.org/10.1001/archinte.1939.00190050019003 DISCLOSURES: No relevant relationships by Aarti Mittal No relevant relationships by Beenish Naqvi
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SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Since the emergence of COVID-19, many serious complications have arisen especially in the setting of Acute Respiratory Distress Syndrome (ARDS) in the intensive care unit. Historically, ARDS and mechanical ventilation is associated with higher rates of pneumothorax. It has been well described that ARDS is the result of inflammatory lung injury, with increased activation of circulating neutrophils, complement and proinflammatory mediators leading to loss of surfactant, alveolar atelectasis, and fibrin deposition. This leads to a less compliant lung parenchyma, and higher airway pressures, which has been attributed as a risk factor for pneumothorax. The management of pneumothorax varies depending on the etiology of the pneumothorax. In the case of iatrogenic pneumothorax (i.e. mechanical ventilation), tube thoracostomy is generally recommended, however the size of the chest tube inserted remains less clear. METHODS: This is a multi-center retrospective cohort study of 88 hospitalized patients with a diagnosis of COVID-19 and pneumothorax or pneumomediastinum between the dates of 3/11/2020 to 01/26/2021. Patient demographics, comorbidities, laboratory and hemodynamic data were collected as well as ventilator settings, lung mechanics, and clinical patient outcome data including type of intervention and rate of resolution of pneumothorax. Final statistical analysis is pending. RESULTS: Our preliminary results reveal that there was a higher rate of resolution of pneumothorax with a large bore chest tube (LBCT) compared to a small bore chest tube (SBCT). There was no significant difference in lung compliance or tidal volume in cc/kg between the patients with a resolving pneumothorax compared to the patients with a nonresolving pneumothorax. Overall mortality rate among all patients was 70.4%. CONCLUSIONS: Patients with a large bore chest tube placed are more likely to have resolution of pneumothorax compared to small bore chest tube or serial X-ray. Lung compliance and tidal volume were not significantly different between patients that had a resolving pneumothorax compared to nonresolving pneumothorax. It is important to manage a pneumothorax early on to reduce associated morbidity. CLINICAL IMPLICATIONS: The development of pneumothorax in COVID patients with ARDS has significant associated morbidity and mortality. Utilization of a large bore chest tube may result in improved rates of resolution of pneumothorax. DISCLOSURES: No relevant relationships by Nathalie Antonios No relevant relationships by Colby Baker No relevant relationships by Jessica Johnson No relevant relationships by Karen Sayad
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Objectives: The purpose of this study was to compare the outcomes of chest tubes (CT) inserted via three approaches in COVID-19 patients undergoing extracorporeal membrane oxygenation (ECMO): open thoracostomies (OT), percutaneously at bedside (PERC), and percutaneously by interventional radiology (PERC IR). Methods: We conducted an institutional review board - approved retrospective study of all COVID-19 patients who required CT placement while undergoing ECMO in our institution from February 2020 till February 2022. Insertions prior to ECMO cannulation or after decannulation, and those related to post-operative lung transplantation during ECMO were excluded from our analysis. Depending on the insertion approach, eligible CT insertion events were divided in three groups: OT, PERC and PERC IR. Data regarding patients' demographics and CT characteristics, clinical indications and associated complications for each group were collected and analyzed. Bleeding related to CT insertion was diagnosed based on requirement of blood transfusion, cessation of anticoagulation and/or ongoing bloody CT output. Results: Study criteria were met by 43 patients, with 35 (83.7%) of male sex. Mean age was 45 years. Mean BMI was 31.6 kg/m2. Forty patients (93.0%) had COVID-related acute respiratory distress syndrome as primary diagnosis. All patients but one had been receiving therapeutic anticoagulation which was held prior to CT insertion. Eighty-seven CT insertion events were recorded, of which 34 (39.1%) comprised the OT group, 20 (23.0%) the PERC group, and 33 (37.9%) the PERC IR group. Table 1 demonstrates a descriptive comparison of CT and insertion data among the three groups. Table 2 depicts the major outcomes among the three groups. Conclusions: For COVID-19 patients on ECMO, insertion of CTs percutaneously by IR is associated with significantly fewer bleeding episodes, transfusions, thoracic consults and explorations in the operating room compared to bedside OT or percutaneous CTs. One third of the percutaneously placed CTs by IR required tube upsizing in the IR suite, a rate still lower compared to the overall CT manipulations or repeat interventions required for CTs inserted via OT or percutaneously at bedside. (Table Presented).
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The novel coronavirus disease (COVID-19) has resulted in a global pandemic. Recently, COVID-19-related pneumothorax has gained attention because of the associated prolonged hospital stay and high mortality. While most cases of pneumothorax respond well to conservative and supportive care, some cases of refractory pneumothorax with persistent air leaks (PALs) do not respond to conventional therapies. There is a lack of evidence-based management strategies to this regard. We describe the case of a 73-year-old man with COVID-19-related acute respiratory distress syndrome (ARDS) who developed delayed tension pneumothorax with PALs caused by alveolopleural fistulas. Despite chest tube drainage, autologous blood pleurodesis, and endoscopic procedures, the PALs could not be closed, and were complicated by thoracic empyema. Subsequent minimally invasive open-window thoracostomy (OWT) with vacuum-assisted closure (VAC) therapy helped successfully control the refractory PALs. Serial chest computed tomography monitoring was useful for the early detection of the pneumothorax and understanding of its temporal relationship with air-filled lung cysts. Our case provides a new perspective to the underlying cause of refractory pneumothorax with PALs, secondary to COVID-19-related ARDS, and underscores the potential of OWT with VAC therapy as a therapeutic alternative in such cases.
ABSTRACT
Aim and background: Coronavirus disease 2019 [SARS-CoV-2] is a serious infectious disease which can cause multiple organ failures especially the lungs. Supportive treatment including invasive and non-invasive oxygen support remains a common therapy. High-flow nasal cannula [HFNC], a non-invasive oxygen support method, has emerged as effective treatment option. Despite its significance in SARS-CoV-2 infection, there is a possible adverse effect of pneumothorax. Many cases of pneumothorax are reported as an initial presentation of COVID-19 infection, but in this report, we present two cases of spontaneous pneumothorax on HFNC in COVID-19 infection. Case 1: A 47-year-old patient, known case of hypertension, got admitted for COVID treatment at our hospital. His PaO2/FiO2 index was 47 on admission and the specific treatment started including non-invasive ventilation. Subsequently, he was put on HFNC to maintain oxygen support. He developed newlyonset cough 4 days prior to pneumothorax. After 13 days on HFNC, right-sided spontaneous pneumothorax developed as a complication. Chest X-ray and lung ultrasound were done to confirm pneumothorax, and a tube thoracostomy was done. However, patient had to be intubated the next day because of decreased saturation on NIV and he died after 2 days of intubation. Case 2: A 34-year-old patient got admitted for COVID-19 pneumonia, without any comorbidities. His PaO2/FiO2 index was 86 on admission and the specific treatment started including non-invasive ventilation. Thereafter, he was put on HFNC to maintain oxygen support. The patient developed cough 5 days prior to pneumothorax. After 8 days on HFNC, patient's oxygen saturation dropped suddenly. He was intubated in emergency, however, suffered cardiac arrest, a few minutes after intubation. Chest X-ray done later showed leftsided massive pneumothorax. Conclusion: Patients on mechanical ventilation are at risk of developing spontaneous pneumothorax. However, HFNC may also be associated with higher chances of barotrauma than other low-flow oxygen therapies, especially in addition to cough. Rapid deterioration of oxygen in a patient on HFNC should be vigilantly monitored for pneumothorax.
ABSTRACT
CASE: A 25-year-old homeless male with nonadherent HIV presented with dyspnea on exertion for 4 days, productive cough for 1 week, fevers, chills and night sweats. He arrived hypoxic to 74% requiring 2L O2 and was cachectic on exam. WBC, lactate and procalcitonin were normal. C-reactive protein was 26.7 mg/L, LDH was 686 units/L and COVID-19 was positive. An arterial blood gas showed a primary respiratory alkalosis with a secondary metabolic alkalosis. Computed tomography of the chest, abdomen and pelvis with contrast showed multifocal large thin-walled cavitary lesions throughout the bilateral lungs with subpleural large cystic disease. Dexamethasone, remdesivir and empiric antibiotics were initiated. Absolute CD4 count was 7 cells/uL with HIV-1 RNA load of 139,000 copies/mL. Sputum was positive for Pneumocystis jirovecii (PCP) by DFA and PCR, but no evidence of mycobacterium. Trimethoprim-sulfamethoxazole (TMP-SMX) was added. On hospital day 13, he developed severe right-sided chest pain, dyspnea and required up to 15L O2. A chest x-ray revealed a large right-sided pneumothorax (PTX) and a chest tube was placed. Cardiothoracic Surgery was consulted for consideration of bullectomy with pleurodesis;this was not recommended as the cystic lesions were extensive with some intraparenchymal. His oxygen requirements improved and his chest tube was removed in 6 days. He was discharged on hospital day 21 to begin prophylactic dosing of TMP-SMX until his CD4 count was over 200 cells/uL and to attend his first appointment at an outpatient HIV clinic the following day. IMPACT/DISCUSSION: Secondary spontaneous pneumothorax (SSP) can be a complication of necrotizing pneumonia due to PCP. In one study, in a cohort of 599 patients with HIV infection, only 1.2% developed a PTX. Bilateral PTX is more common with PCP, unlike in our patient. In HIV, the degree of immunosuppression can influence the cause of PTX. Our patient had a PTX with a CD4 count under 200, which is more common with PCP. In addition, SSP as a complication of SARS-CoV-2 is more rare. There are case series that describe COVID-19 patients who develop PTX in the absence of barotrauma secondary to mechanical ventilation. However, this is uncommon as one retrospective study reports PTX occurring in 1% of patients with COVID-19 requiring hospital admission. In this case, it is unclear to what extent the patient's concomitant COVID-19 contributed to the development of a PTX. Our patient was ineligible for definitive intervention to prevent recurrence, thus underwent tube thoracostomy placement which is consistent with the majority of treated patients. While the prognosis of PTX secondary to COVID-19 is generally good, prognosis of cominant co-infection with PCP is an area of further research as the overall mortality of PCP-induced PTX alone can be 23%. CONCLUSION: This case represents a rare occurrence of spontaneous pneumothorax secondary to both PCP and COVID-19. We suggest the incidence to increase as the pandemic continues.
ABSTRACT
LAY SUMMARY Traumatic injury is the most common cause of death among young people. Most victims of trauma die alone before medical response is possible. Typical causes of death are not overly complex to fix if access to standard hospital interventions is feasible. Dying victims are often connected to smartphone-supporting informatic communication technologies, which make available a worldwide network of experts who can potentially reassure and remotely diagnose victims and provide life-saving advice. TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) researchers have focused on empowering point-of-care providers to perform outside their scope and deliver life-saving interventions. With the recognition that coronavirus disease 2019 (COVID-19) has profoundly isolated many people, solutions to respect COVID-19 isolation policies have stimulated the TMUSMI group to appreciate the potential for informatic technologies' effect on the ability to care for oneself in cases of catastrophic injury. Most traumatic death occurs pre-hospital, before a victim ever encounters a health care provider, whether in military or in civilian settings. Many of these deaths have been accepted as unpreventable, especially when severe injuries occur to isolated victims, with no possibility of rescuers responding. A double paradox is that dying individuals often have anatomically simple wounds with complex physiology. These individuals are physically dying alone while virtually connected via smartphone to a potential worldwide network of life-saving mentors - many of whom have the comprehensive library of human resuscitative science at their virtual fingertips. If a seriously injured victim is not immediately incapacitated, then many techniques to empower point-of-care self-resuscitation exist, including both remotely telementored and video-modelled diagnostic, resuscitative, and interventional procedures. This article discusses a small but evolving database and proposes developmental pathways to attempt to ensure that no conscious, dying victim ever dies alone without at least trying to save themselves or receiving comforting words through virtual expert help.
ABSTRACT
Background: COVID19 infection is caused by the highly contagious SARS-CoV-2(Severe acute respiratory syndrome coronavirus 2). The first outbreak of this infection was in Wuhan, China in December 2019. Since then, it has spread rapidly across the world, with more than 100000 new cases each day. Among those infected with SARS-COV-2 up to 20% develop severe disease requiring hospitalization. Among those who are hospitalized, one quarter will need ICU admission. Admission to the ICU is due to respiratory failure or pneumonia. The pneumonia associated with COVID19 infection may lead to respiratory failure requiring endotracheal intubation and mechanical ventilation. An important complication of mechanical ventilation is barotrauma. Barotrauma appears to be common in COVID19 patients. Pneumothorax developed in 25% of COVID19 patients who had barotrauma. In COVID19 the percentage of patients with mild symptoms who develop a pleural effusion is 8% compared to 28% in patients who are critically ill. Most of the COVID19 infected that have a pneumothorax or pleural effusion need a thoracostomy. In trauma cases most, thoracic injuries (leading to pneumothorax or hemothorax) are effectively treated with tube thoracostomy. Objectives: First objective is to compare the therapeutic effect of tube thoracostomy on COVID19 infected patients who have pneumothorax or pleural effusion to those non-COVID19 infected patients who had traumatic pneumothorax or pleural effusion treated by tube thoracostomy. Second objective is to study the morbidity associated with tube thoracostomy in COVID19 infected patients who have pneumothorax or pleural effusion. Patients and methods: This study was conducted in Sheikh Khalifa medical city Ajman, United Arab Emirates. It is a descriptive, observational, retrospective cohort study. One hundred patients were recruited from the January 1, 2020 to the December 31, 2020. Patients were divided into two groups. First group includes fifty adult COVID 19 infected patients who had no trauma. Second group includes fifty adult COVID19 infection free patients who had trauma. Inclusion criteria for the first group: COVID 19 infected patients with an age equal to or above 18 years, of both genders, with history of pneumothorax, pleural effusion or both of them, needed insertion of thoracostomy chest tube. Inclusion criteria for the second group: Patients with an age equal to or above 18 years, of both genders, with history of traumatic pneumothorax, pleural effusion (hemothorax) or both of them, needed insertion of thoracostomy chest tube. Exclusion criteria for the first group: Children, Adult COVID19 infected patients who didn't have pneumothorax or plural effusion, adult COVID19 infected patients who had pneumothorax or plural effusion without a need for tube thoracostomy. Exclusion criteria for the second group: Adult non-COVID19 infected patients who had trauma, but didn't have pneumothorax or pleural effusion, adult non-COVID19 infected patients who had traumatic pneumothorax or pleural effusion without a need for tube thoracostomy. The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 25). Mann Whitney Test (U test) was used to assess the statistical significance of the difference of a non-parametric variable between two study groups. Chi-Square test was used to examine the relationship between two qualitative variables. Fisher's exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells. Results: Most of patients in trauma group (group 2) were with the age range of 20-40-year (58.8% of patients) P value was significant (<0.001). In COVID 19 infected patients' group (group 1) the age range was 40-60 year (50%of patients). P Value (<0.001) was significant too. Male was the dominant gender in group 2 (96.1% of patients were male), while in group1 (78% of patients were male), P Value was significant (0.007). No co-morbidities (diabetes, hypertension, ischemic heart disease, Asthma and dyslipidemia) were detected in group 2 (0.0%). Co-morbidity were detected in 76% of patients in group 1, P Value was significant (<0.001). Hemothorax occurred in 37.3% of patients in group 2, and no cases of hemothorax was detected in group 1. P Value was significant (<0.001). Complications of chest tube insertion took place in group 2 as follows; tube malposition in 13.7% of patients, tube blockade in 3.9% of patients. The percentage in group 1 was as follows tube malposition in 16% of patients, tube blockade in 18%. The difference between the two was not significant for tube malposition (P value 0.748) and significant for tube blockade (P value 0.023). Subcutaneous emphysema occurred in 15.7% of patients in group 2 and in 15.7% of patients in group 1. The difference was not significant (P value was 0.118). Acquired bronchopleural fistula occurred 2.0% of group 1 cases. No cases of this fistula were documented in group 2. Number of chest tubes needed to be inserted in group 2 patients was as follows (one chest tube in: 74.5% of patients, two chest tubes in: 23.5% of patients. Three chest tubes or more in 2% of patients). While in group1 patients' number of chest tubes needed to be inserted was (one in 56% of patients, two in 30% of patients. Three or more in 14% of patients). The difference was significant only in those who required insertion of three chest tubes or more (P value was 0.028). The median duration needed to keep a chest tube was 3 days in group 2, and 7 days in group 1. The difference between the two was significant (P value was 0.000). Death was the fate of 3.9% of patients in group 2 and in 64% of patients in group 1. The difference was significant (P value was< 0.001). Conclusion: Therapeutic effect of tube thoracostomy in treating Adult COVID19 patients who had pneumothorax or pleural effusion is less than that used in treating trauma non-COVID19 patients who had pneumothorax or plural effusion. Morbidity and mortality related to tube thoracostomy applied to treat pneumothorax or pleural effusion in adult COVID19 patients is more than that in trauma non COVID 19 patients.
ABSTRACT
Introduction: Naso-(NGT) and oro-gastric tubes play an integral role in the nutritional support of patients who are not able to meet dietary needs through independent oral consumption. Although uncommon, serious pulmonary complications may arise from this mostly blindly performed procedure (0.2-2%). We report a case of an elderly female who developed a right-sided tension pneumothorax (PTX). necessitating tube thoracostomy following NGT misplacement. Case: Our patient is a 79-year-old elderly female woman with no known past medical history who was admitted for altered mentation and hypoxemia due to COVID-19. Although her initial course was complicated by progressive respiratory failure requiring ICU admission and initiation of high-flow nasal cannula, she was quickly weaned to nasal cannula and transferred to a regular floor. Due to poor mentation and inconsistent food intake, enteral access was attempted using a weighted-tip 10 FR NGT. The patient had mild cough and discomfort during the procedure. There was no resistance during insertion. After advancement to 55 CM the patient ceased coughing and the procedure was completed. Chest X-ray (CXR) obtained as part of routine post-procedural evaluation revealed an intra-pleural NGT abutting the R hemi-diaphragm (Figure) and small PTX. Follow-up CXR revealed enlarging PTX with mediastinal shift to the left for which emergent thoracostomy utilizing a 14FR pig-tail catheter was performed. There was complete resolution of the pneumothorax with removal of the chest tube three days later. The patient was discharged home shortly after. Discussion: NGT placement is commonly performed by healthcare providers of varying degrees of expertise and experience. Risk factors associated with complications include multiple attempts, insertion at night, presence of artificial airway and altered mentation, among others. In case of trans-pulmonary placement, withdrawal of intra-pleural NGTs is associated with high risk of pneumothorax and requires close observation. To decrease the likelihood of malposition, a two-step radiograph, gradual progression technique can be deployed if fluoroscopic placement is not available. This should be strongly considered in patients at high risk for adverse events. Conclusions: Blind insertion of NGT using traditional techniques may be of limited safety and put patients at risk of complications. This is particularly true in those who are critically ill, frail or experiencing altered mentation. Institutional protocols to identify patients at high risk on whom blind placement should not be attempted are warranted. Post-withdrawal CXR to rule-out the presence of tension physiology is highly recommended.
ABSTRACT
ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.
ABSTRACT
Background: COVID-19 is associated with an increased risk of superimposed bacterial and fungal infections. Pleural aspergillosis is an uncommon manifestation of invasive aspergillosis. We report a case of pleural aspergillosis with pulmonary artery thrombosis after COVID-19 with favourable outcome. Case Study: A 67-year male, diabetic, IHD post CABG, with moderate COVID-19 disease 2 months ago, presented with 1 week history of productive cough, breathlessness and chest pain. Examination revealed hypoxia, tachycardia and diminished breath sounds on right side. Right hydropneumothorax was noted on imaging, tube thoracostomy was done. Pleural fluid investigations were suggestive of pyothorax. CECT-thorax showed cavitary consolidation in right lower lobe. Patient was treated with IV antibiotics. However, there was persistent air leak and tachycardia. 2D-ECHO showed mild PAH. D-Dimer was high, CTPA revealed partial thrombosis of right posterior basal pulmonary arteries. Pleural fluid fungal culture yielded Aspergillus fumigatus. Patient was initiated on oral voriconazole and anticoagulants. He showed marked improvement and in 5 days ICD was removed. Patient is on regular follow-up. Discussion: COVID-19 associated superimposed infections have been reported with high mortality rates. The use of corticosteroids and/or IL-6 antagonists have been implicated with the fungal infections. Pleural aspergillosis is rare. Diagnosis is usually based on clinical and microbiological evidence. A key finding in invasive aspergillosis is angioinvasion which leads to thrombosis and tissue infarction. Conclusion: Clinicians should have high index of suspicion for superimposed fungal infections in COVID-19. Early initiation of treatment brings down morbidity and mortality.
ABSTRACT
Background: COVID-19 has become a dreadful pandemic. One of the important complication is the development of pneumothorax/ pneumomediastinum which gets further complicated by bronchopleural fistula. Case Study: A 44year male patient with severe COVID pneumonia developed Left sided pneumothorax and treated conservatively with ICD and negative suctioning for 2 months and referred to us with persistent pneumothorax with BPF. As patient was unfit for surgery, bronchoscopic management was planned. With flexible bronchoscope, 6F Fogarty balloon was passed and inflated, leak site was identified in left upper lobe upper division. A Watanabe spigot size 5 was deposited at the opening of upper division and manipulated to apical segment. Other small openings were sealed with cyanoacrylate glue and autologous blood patch. After procedure negative suction was reapplied. Repeat Xray showed resolution of pneumothorax. Pleurodesis was done with talc slurry, post pleurodesis showed no pneumothorax and ICD was removed. Patient was discharged, follow up X ray after 4weeks showed no evidence of pneumothorax. Discussion: In most cases of BPF, leak seals after tube thoracostomy, only 3-5% will continue to have persistent leak. For medically inoperable cases, bronchoscopic balloon occlusion of site and subsequent injection with fibrin glue, liquid bioadhesive or blood patch can be done. For large leak;Amplatzer device, stents, spigots, coils are used. Conclusion: Bronchoscopic treatment can work well for a medically inoperable, complicated pneumothorax in COVID-19 disease.