ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Secondary spontaneous pneumothoraxes commonly occur in patients with cystic fibrosis (CF) and can be complicated by persistent air leak (PAL) due to bronchopleural or alveolopleural fistula. More recently, bronchoscopic placement of one-way endobronchial valves (EBV) for PAL have been explored. We present the first case series of patients with CF who developed secondary spontaneous pneumothoraxes and were successfully treated with EBV. CASE PRESENTATION: A 30-year-old female with CF (F508del/dupex6B-10) and history of pneumothorax, presented with acute hypoxic respiratory failure. She was found to have a right-sided pneumothorax. A chest tube was placed, with a continuous air leak for 4 days. She was a suboptimal surgical candidate given extensive apical lung disease, making localization of the air leak difficult. In addition, the increased tissue density would have made wedge resection challenging. After multidisciplinary discussion, the patient underwent placement of 5 Zephyr EBV (Pulmonx Inc., Redwood City, CA) for PAL. The lung had re-expanded, but there was still an intermittent air leak. She underwent pleurodesis with betadine. Her chest tube was removed 2 days later, and she was discharged. She was seen in the pulmonary clinic 5 days after being discharged and was noted to have recurrent right pneumothorax. She underwent chest tube placement with flutter valve. The chest tube was removed after 10 days. The patient was scheduled for removal of EBV 6 weeks after placement, but the procedure was delayed to symptomatic COVID-19 infection. EBV were eventually removed 12 weeks after placement. Pneumothorax has not recurred 6 weeks post EBV removal. A 53-year-old female with CF (394delTT/3272-26A-G) and a small right apical secondary spontaneous pneumothorax 3 months prior to hospitalization presented with progressive dyspnea. Imaging showed that the pneumothorax had enlarged. A chest tube was placed with continuous air leak. After a multidisciplinary discussion, 5 Zephyr EBV were placed 2 days later. There was immediate improvement of the pneumothorax, with almost no air leak. Her chest tube was removed 48 hours after placement of EBV, and patient was discharged on day 4. The EBV were removed 8 weeks later with no recurrence of pneumothorax 1 month after valve removal. DISCUSSION: To our knowledge this is the first case series describing the use of Zephyr EBV in CF patients with secondary spontaneous pneumothorax complicated by PAL. Although previous guidelines still recommend surgery and/or pleurodesis for PAL, this may not be the best option for patients with CF who may require lung transplantation. EBV are currently FDA approved for lung volume reduction to treat emphysema, but it is likely a viable non-surgical alternative for PAL. CONCLUSIONS: EBV is a well-tolerated treatment option for PAL due to secondary spontaneous pneumothoraxes. Reference #1: Bongers KS, De Cardenas J. Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema. J Cyst Fibros. 2020 Sep;19(5):e36-e38. doi: 10.1016/j.jcf.2020.03.014. Epub 2020 Apr 18. PMID: 32312675. Reference #2: Travaline JM, McKenna RJ Jr, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, Criner GJ;Endobronchial Valve for Persistent Air Leak Group. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009 Aug;136(2):355-360. doi: 10.1378/chest.08-2389. Epub 2009 Apr 6. Erratum in: Chest. 2009 Sep;136(3):950. PMID: 19349382. Reference #3: Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417-423. doi: 10.1016/j.chest.2017.02.020. Epub 2017 Mar 4. PMID: 28267436;PMCID: PMC6026238. DISCLOSURES: No relevant relationships by Bryan Benn no disclosure on file for Julie Biller;No relevant relationships by Rose Franco Speaker/Speaker's Bureau relationship with Biodesix Please note: 2018 - present by Jonathan Kurman, value=Honoraria Consultant relationship with Level Ex Please note: 2018 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Medtronic Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Pinnacle Biologics Please note: 2020 - present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Consultant relationship with Boston Scientific Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Consultant relationship with Cook Medical Please note: 2021 - present by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Erbe Please note: 2021 - present by Jonathan Kurman, value=Honoraria research panel relationship with Intuitive Please note: 2020 - present by Jonathan Kurman, value=Honoraria Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Pulmonx Please note: 2020 - present by Jonathan Kurman, value=Consulting fee Travel relationship with Ambu Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Travel Removed 04/01/2022 by Jonathan Kurman Consultant relationship with Ambu Please note: 2022-present Added 04/01/2022 by Jonathan Kurman, value=Consulting fee Speaker/Speaker's Bureau relationship with Veracyte Please note: 2021-present Added 04/01/2022 by Jonathan Kurman, value=Honoraria No relevant relationships by Shreya Podder

Cerebrovascular Manifestations of COVID-19 in Young Adults

Objective: The aim of this study was to characterize patients hospitalized with COVID-19 and cerebrovascular disease, with a focus on young patients diagnosed with CVST and ICH/SAH. Background: There have been many reported neurologic manifestations of coronavirus disease 2019 (COVID-19) including cerebrovascular events such as ischemic stroke, hemorrhagic stroke including intracerebral hemorrhage/subarachnoid hemorrhage (ICH/SAH) and central venous sinus thrombosis (CVST). However, there has not been much focus on this topic in young adults aged under 50. Design/Methods: Retrospective chart review was used to obtain parameters of patients hospitalized in Chicago area hospitals with COVID-19 and a neurologic diagnosis including acute ischemic stroke, subarachnoid hemorrhage, intracranial hemorrhage, and cerebral venous sinus thrombosis. Data including patients' comorbidities and disease course was entered into a secure database by representatives from 4 different tertiary care centers. Results: A total of 27 patients aged 18 to 50 were hospitalized in Chicago land tertiary care centers from March 30, 2020 to February 1, 2021 with cerebrovascular disease and concurrently tested positive for COVID-19. Of these patients, 2 were found to have venous sinus thrombosis. 9 patients had hemorrhagic strokes, of these, 4 patients with ICH were thought to have had spontaneous hemorrhages. 9 of 27 patients had no past medical history. Conclusions: This population had a large portion, 11 out of 27 patients, with non-ischemic cerebrovascular insults such as CVST, ICH, or SAH while concurrently infected with COVID-19. Unlike most classic patients who develop these conditions, our population did not have traditional risk factors such as smoking or hypertension. Systemic inflammation, hypoxia, platelet dysfunction, or hyper-coagulability due to COVID-19 are theorized as the cause of these cerebrovascular manifestations in the absence of traditional risk factors. Spontaneous cerebrovascular manifestations of COVID-19 continue to be investigated, particularly in younger patients without traditional risk factors.

OPIOID-FREE SURGERY: IMPLEMENTATION OF SUCCESSFUL NON- OPIATE COLECTOMY AT COMMUNITY TEACHING CENTER

Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.

Global impact of the COVID-19 pandemic on stroke care and intravenous thrombolysis

Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods. Background: The COVID-19 pandemic led to widespread repercussions on the delivery of health care worldwide. Design/Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by ICD-10 codes and/or classifications in stroke center databases. Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI,-11.7 to-11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI,-13.8 to-12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI,-13.7 to-10.3, p=0.001). There were greater declines in primary compared to comprehensive stroke centers (CSC) for stroke hospitalizations (-17.3% vs-10.3%, p<0.0001) and IVT (-15.5% vs-12.6%, p=0.0001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) months of the pandemic, with greater recovery in hospitals with lower COVID-19 hospitalization volume, high volume stroke center, and CSC. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months, with greater recovery in hospitals with lower COVID-19 hospitalizations, high volume stroke centers, and CSCs.

Characteristics of a diverse cohort of stroke patients with sars-cov-2 and outcome by sex

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. We describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease, and investigate the role of sex on outcome. Methods: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers from Chicago metropolitan area. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results: The study included 83 patients. Median age was 64 years and the majority were Blacks (47%) followed by Hispanics (28%) and whites (16%). Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Higher proportions of male experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%;p=0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%).Compared to female, males had higher mortality (38% vs. 13%;p=0.02) and were less likely to bedischarged home (12% vs. 33%;p=0.04). After adjustment for age, race/ethnicity, and number ofVRFs, mRS was higher in males than in females (OR=1.47, 95% CI=1.03-2.09) Conclusion: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence ofcoronavirus infection on admission and preexisting VRFs. Severe in-hospital complications andworse outcomes after ischemic strokes were higher in males, than females.

Characteristics of a Diverse Cohort of Stroke Patients with SARS-CoV-2 and Outcome by Sex.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. METHODS: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. RESULTS: The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03-2.09). CONCLUSION: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.