BACKGROUND:Obstructive sleep apnea (OSA) is a chronic respiratory disorder associated with repeated nocturnal partial or complete collapse that is often underdiagnosed and associated with multiple comorbidities. The association between specific features on an electrocardiogram and OSA has not been well studied. This retrospective study attempts to bridge this gap in knowledge. METHODS:A total of 265 patients' medical records were reviewed retrospectively. Specific features of their electrocardiograms and their association with the severity of OSA were studied from April 2014 to May 2016. 215 patients were included in the final analysis. Tests of group difference between OSA patients and controls were done using student's t-tests for continuous variables and using chi-square tests for categorical outcomes. Multivariate tests of differences between OSA and control patients were done using logistic regression to control for possible confounding factors. RESULTS:A total of 215 patients with diagnosed OSA and 41 controls in whom OSA was ruled out using polysomnography were compared. Males were more likely to present with OSA than females (93 % versus 76 %; p < 0.001). OSA patients were also significantly older: 52.18 ± 14.04 versus 44.55 ± 14.64; p = 0.002. Deep S waves in V5-6 (p=0.014) and RS pattern with Deep S waves in leads I and AVF (p=0.017) were both significantly associated with OSA based on univariate comparisons. These findings lost significance in the multivariate analysis. CONCLUSION:The idea of using an electrocardiogram in aiding in the assessment of OSA is attractive and feasible, as it is a safe, noninvasive, and cost-effective method. Our results can be used for early risk stratification in patients with OSA.

Soni, Parita; Aggarwal, Nidhi; Rai, Anand Kumar; Saradna, Arjun; Pascal, William; Kupfer, Yizhak Author Information

Soni, Parita; Patel, Jignesh; Aggarwal, Nidhi; Rai, Anand Kumar; Kupfer, Yizhak Author Information

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lymphomas commonly present with constitutional symptoms and lymphadenopathy. Rarely do they present as endobronchial tumors (1). We report a rare case of endobronchial presentation of Hodgkin's Lymphoma. CASE PRESENTATION: 66-year old female with diabetes, hypertension, Hodgkin's lymphoma (diagnosed 1 month prior, with an excisional biopsy of cervical lymph node) status post 1 dose of Rituximab, presented to the ER with fever, cough, chills and a purulent carbuncle on her right thigh. She was afebrile, tachycardic with a heart rate of 107 but otherwise had normal vitals, with an oxygen saturation of 100% on room air. Laboratory results showed Hemoglobin and Hematocrit of 7.4 g/dL and 23.8, and lactic acid of 3.8 mmol/l. CT chest showed multiple patchy opacities in both lungs, large consolidation in the lingula (new compared to her previous scan done 6 weeks earlier), stable mediastinal adenopathy and bilateral axillary adenopathy which was new. Patient was started on broad spectrum antibiotics to cover pneumonia and bronchodilators for symptomatic relief. Despite this patient continued to worsen with regard to her respiratory symptoms requiring commencement of systemic steroids for bronchospasm. Even though she had symptomatic relief, repeat chest imaging showed worsening of lung infiltrates and hence she underwent bronchoscopy. Bronchoscopy showed an endobronchial mass in the left main stem bronchus, resembling a mucus plug. Core biopsy and brushings were sent for histopathological analysis which showed Hodgkin's lymphoma, classical type. Patient was started on chemotherapy and is currently being followed up in our cancer center. DISCUSSION: Hodgkin's disease of the lung usually presents as mediastinal lymphadenopathy (2). Presentation of Hodgkin's disease as an endobronchial lesion is uncommon (<5%). The possible mechanism responsible for endobronchial disease is either by direct bronchial invasion or by hematogenous dissemination. Patients usually develop respiratory symptoms due to compression of the airways. Gross appearance of the lesion can mimic small cell cancer. It has been proposed that to be recognized as an endobronchial presentation of Hodgkin's disease, the case has to fulfill the following criteria at the time of initial diagnosis: (i) histological features of Hodgkin's disease (whatever the site of biopsy) and (ii) bronchoscopic visualization of an endobronchial tumor. It is a potentially curable disease with dual chemotherapy regimen. CONCLUSIONS: A bronchoscopy may be warranted in patients that have been diagnosed with Hodgkin's lymphoma and develop new respiratory symptoms. Though infections should always be in the differential diagnosis, especially as these patients are also immunocompromised, the possibility of endobronchial involvement must be considered. If unrecognized, this can lead to under-staging of a potentially curable disease, that can compromise the cure. Reference #1: 1. Prakash R. Malur, Gajanan S. Gaude, Hema B. Bannur, Shivappa B. Anurshetru, Vijayalaxmi V. Suranagi, Ranjit P. Kangle, Annasaheb J. Dhumale, Pradeep H. Patil, and Reshma Davanagere. Primary endobronchial Hodgkin's disease. Lung India. 2009 Oct-Dec; 26(4): 136–138. Reference #2: 2. Ben Naoum Y, Chapuis E, Coste E, Marty-Double C, Vincent D. [Bronchial presentation of stage IVB Hodgkins disease]. Rev Mal Respir. 2004 Jun;21(3 Pt 1):599-601. DISCLOSURES: No relevant relationships by Anna Abbasi, source=Web Response No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Kabu Chawla, source=Admin input No relevant relationships by William Pascal, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Ben Shamian, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

SESSION TITLE: Critical Respiratory Care SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 07:30 AM - 08:30 AM PURPOSE: High flow nasal cannula (HFNC) oxygen(O2) therapy delivers heated and humidified gas with flow rates up to 60 L/min. It also provides a small PEEP effect, reduces anatomical dead space, and provides a constant fraction of inspired oxygen(FiO2). It has been extensively studied in pediatric population and has lately gained popularity in adult patient population although evidence for use in critically ill adults still remains poor. Additionally, to our knowledge, evidence of its use in patients 80 years of age and above has not been assessed. We attempt to study the indications and effects of HFNC use in patients 80 years of age and above in the medical intensive care unit (MICU) of a tertiary care hospital. METHODS: 40 patients 80 years of age and above who required HFNC O2 in the MICU for more than 12 hours between 01/01/2016 and 08/01/2017 were identified. Retrospective chart review was performed and data related to HFNC O2 use was obtained. Data included age, diagnosis, indication for HFNC, duration of HFNC use, initial FiO2 and flow rate, modality of oxygenation used before and after HFNC, disposition and code status. The data was charted on a spreadsheet and analyzed by calculating percentage associated with various variables. RESULTS: Mean age of the patients was 89.025 years. Mean duration of HFNC O2 use was 5 days. Mean initial FiO2 was 45.625%. Mean initial flow rate was 42.75 L/min. Most common indication for HFNC use was hypoxemia post extubation. Most common diagnosis was sepsis due to pneumonia. 52.5%(21/40) patients were transitioned to HFNC O2 post extubation. 47.5%(19/40) were transitioned from nasal cannula(NC) or bilevel positive airway pressure ventilation (BPAP). 15%(6/40) had to be intubated and mechanically ventilated after HFNC O2 use whereas 85%(34/40) were downscaled to regular NC O2. Of the 6 intubations, 3 were re-intubations. 12.5%(5/40) patients expired whereas 87.5%(35/40) patients were discharged from the hospital. Code status for 4 patients was changed to comfort care with do not intubate(DNI) after extubation to HFNC, 2/4 were discharged and the other 2 expired. CONCLUSIONS: This study revealed a positive outcome with respect to use of HFNC O2 in patients 80 years of age and above. Majority (87.5%) of the patients were discharged from the hospital. Intubation(15%) and re-intubation rates were low after use of HFNC O2. Patients who opted for comfort care (DNR/DNI) but could not maintain optimum oxyhemoglobin saturation with NC O2 and found BPAP uncomfortable, benefitted from HFNC with respect to comfort and compliance per chart review. CLINICAL IMPLICATIONS: Elderly patients might benefit from HFNC O2 especially after liberation from mechanical ventilation. Elderly patients with hypoxemic respiratory failure who opt for comfort care but cannot maintain optimum oxyhemoglobin saturation with NC O2 and find BPAP uncomfortable could also benefit from HFNC O2 use. DISCLOSURES: No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ben Shamian, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare clinical entity presenting with recurrent pneumothorax in women of reproductive age (1). Presence of ectopic endometrial tissue in thorax leads to their activation with each menstrual cycle. We report a unique case of a young female who presented with recurrent spontaneous pneumothorax despite video assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 36-year-old female with history of endometriosis, CP status post VATS about 4 months prior to this presentation, DVT, was referred to our ER for admission after she was found to have large right pneumothorax on a CT chest done as outpatient for chest discomfort. She was hemodynamically stable with SpO2 97% on room air. CT chest revealed a very large loculated right pneumothorax with left mediastinal shift and extensive pleural thickening. Initially she underwent a pigtail catheter placement in the largest pocket. Despite the pigtail drainage, patient continued to have air leak and mediastinal shift. Thus, a decision was made to perform VATS again. Pleural biopsy and VATS pleurodesis were performed with placement of 12F, 19F, 28F chest tubes. Mediastinal shift resolved but she continued to have small pneumothorax. On day 16, she was discharged with a chest tube and outpatient follow-up. Chest tube was removed on one week follow up in the clinic. She continued to have small loculated right sided pneumothorax. Pleural biopsy obtained during VATS, showed positive paired-box gene8 (PAX8) in epithelial lining compatible with presence of endometrial tissue in pleura. She is currently on progesterone only mini pill and is closely followed up in clinic. DISCUSSION: Thoracic endometriosis is the most common site for extra pelvic endometriosis with CP being a common presentation. It mostly affects right side (85-90%) like in our case. Characteristic findings associated with CP include defects of diaphragm like perforation, stomata, pores and fenestrations, which can vary in size, shape and numbers (2). With this case, we emphasize that the physicians should be aware of this relatively uncommon clinical entity when encountering young female with recurrent pneumothorax. Even after confirmed diagnosis, CP poses a treatment challenge as it can continue to cause recurrent large pneumothoraces despite VATS and hormonal therapy. Patients can develop pleural thickening and loculations which makes management of future pneumothoarcses even more difficult. No clear guidelines exist on management of CP. With the disease affecting young population and having a significant effect on lifestyle, it is prudent that more research should be done for CP management. CONCLUSIONS: CP is an uncommon cause of recurrent pneumothorax. Histologic finding of endometrial tissue on pleural biopsy is often required to confirm the diagnosis. CP is usually managed with hormonal therapy and VATS but needs further investigation. Reference #1: Bagan P, et al. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg 2003;75:378-81. Reference #2: Visouli AN, et al. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thorac Dis. 2012 Nov;4(Suppl 1):17–31. DISCLOSURES: No relevant relationships by Nidhi Aggarwal, source=Web Response No relevant relationships by Vivek Kumar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Jignesh Patel, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Rasmussen aneurysm (RA) is a rare vascular complication after mycobacterium tuberculosis (MTB). We report a rare case of a male who was treated for MTB 7 years ago and now presented with massive hemoptysis and was found to have RA. CASE PRESENTATION: A 72-year-old man, former smoker with history of asthma and MTB presented to the ER with hemoptysis for 2 weeks. He also complained of left sided sharp chest pain and shortness of breath, subjective fever, chills and drenching night sweats. He immigrated to the US 3 years ago. He denied any recent travel, sick contacts or weight loss. On presentation, his vitals were stable. Lab work revealed no leukocytosis or coagulopathy. Chest X-Ray showed a left upper lobe cavity. He was placed under airborne isolation and was started on RIPE therapy empirically. Sputum/Bronchoalveolar lavage acid fast bacilli (AFBs) culture and MTB PCR assay were negative. RIPE therapy was discontinued. CT angiogram of the chest showed enhanced dilated vessel within the old TB cavity consistent with RA in the setting of history of TB. Aortogram showed hypertrophied left bronchial artery. He underwent embolization of left bronchial artery but continued to have massive hemoptysis. Bronchoscopy with endobronchial blocker placement was done. patient was too unstable to undergo any more procedures. Despite multiple efforts, patient continued to have episodes of massive hemoptysis over next 10 days. By day 11, patient was in severe ARDS. Family decided to palliative extubate him and he expired soon after. DISCUSSION: This case demonstrates that RA is a very rare vascular complication encountered in the patients with history of TB and has only been seen in 4% of the patients on autopsy (1, 2). It can present with multiple episodes of minor hemoptysis or an episode of massive hemoptysis. The pathophysiology can be explained by any destructive lung pathology eroding the adjacent structure (). When it involves the vessel walls, the media gets destroyed and the thick intima protrudes out to form an aneurysm. By using the available newer imaging modalities and more advanced interventional radiology techniques, we could diagnose RA in our patient. Management is often challenging and patients may continue to bleed and deteriorate. Endovascular occlusion of the neck of the pulmonary aneurysm, coiling and embolization when feasible can be lifesaving. We emphasis that when presented with massive hemoptysis in setting of old TB RA should be entertained in differential diagnosis. CONCLUSIONS: RA is a rare but important cause of life threatening hemoptysis. Timely diagnosis and management is crucial for successful outcome. Reference #1: Corr P. Pulmonary artery aneurysm as a cause of massive hemoptysis: diagnosis and management. Case Rep Radiol. 2011;2011:141563. Reference #2: Santelli ED, et al. Embolization of multiple Rasmussen aneurysms as a treatment of hemoptysis. Radiology. 1994 Nov;193(2):396-8. DISCLOSURES: No relevant relationships by Nidhi Aggarwal, source=Web Response No relevant relationships by Arindam Ghatak, source=Web Response No relevant relationships by Vivek Kumar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response No relevant relationships by Omar Taha, source=Web Response

A 22-year-old Asian woman presented with respiratory distress, cough, and wheezing for 1 week. Prior history included asthma and Turner syndrome. On presentation to the emergency department, the patient was hypotensive, tachycardic, tachypneic, with an oxyhemoglobin saturation in the mid 80% range while breathing ambient air. Chest radiograph revealed pulmonary vascular congestion and a left lower lobe infiltrate. Endotracheal intubation, mechanical ventilation, and vasopressors were initiated. Empiric therapy for community-acquired pneumonia was administered utilizing broad-spectrum intravenous antibiotics. Routine sputum culture was negative for pathogens. Nasopharyngeal swab submitted for multiplex amplified nucleic acid testing yielded enterovirus-human rhinovirus (EV-HRV). Thus, the diagnosis of EV-HRV pneumonia complicated by acute respiratory distress syndrome (ARDS) was established. Multiple attempts to wean from the ventilator were unsuccessful, and a tracheostomy was performed. This report highlights EV-HRV as a cause of severe ARDS and prolonged respiratory failure in adults.

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Bacteroides vulgatus (BV) is an anaerobic gram negative bacilli of bacteroides fragilis group. It is a part of normal human bacterial flora, predominantly in the colon. When pathogenic it can cause bacteremia and abscesses at multiple sites (1). We report a case of an elderly female who initially presented as lung mass but was found to have an extremely rare cause of a massive liver abscess. CASE PRESENTATION: A 76-year-old female with history of asthma and colon cancer with right hemicolectomy presented to the ER with progressively worsening shortness of breath for 3-weeks. She also complained of right lower chest pain and discomfort. She denied any nausea, vomiting or diarrhea. She was afebrile with normal vitals. Lung exam was remarkable for significantly decreased breath sounds at right base. Abdomen was mildly tender in RUQ with some dullness to percussion. Labs showed no leukocytosis, with normal renal and liver function. Chest X-ray was reported to have an opacity in the right lower lung with mediastinal shift and prominent right hilum compatible with tumor or pleural effusion (Figure 1). CT angiogram of the chest showed 21x17x15 cm complex liver cyst with mass effect causing near-complete atelectasis of the right lung (Figure 2). The patient underwent CT guided drainage of the liver cyst with drainage of 2.5 L of “anchovy paste” pus. She was started on empiric antibiotics. Two days later patient started complaining of pain again and a repeat imaging showed reaccumulation of the fluid. The collection was drained again and a 10 Fr catheter was placed for continuous drainage. Cultures grew BV. Serum echinococcus and entamoeba histolytica immunoglobulin G (IgG) antibody came back negative. Serial imaging showed gradual resolution of the abscess. It drained completely over next 4 weeks and the catheter was then removed. Patient was treated with IV ceftriaxone and metronidazole for 4 weeks. She continued to do well on the follow up visit. DISCUSSION: Even though anaerobic liver abscesses are fairly common, abscess due to BV is extremely rare. To our knowledge, this is the first reported case of liver abscess due to BV. The infection is introduced into the hepatic parenchyma from intestinal flora via biliary tract or portal venous system. Our case emphasizes three important concepts: 1) Infection with BV can mimic amoebic liver abscess with “anchovy paste” appearance, 2) BV even though rare, can lead to a massive liver abscess requiring long term drainage and antibiotics, and 3) Massive BV liver abscesses can present solely with pulmonary symptoms and initial radiological imaging such as Chest X-ray may be misleading. CONCLUSIONS: “Anchovy paste” liver abscess is not always equivalent to “amoebic” liver abscess. It is important to identify the exact etiological agent of such abscesses, as some of these may need long term antibiotics with drainage and follow up. Reference #1: Wexler HN. Clin Microbiol Rev. 2007;20(4):593-621. Doi:10.1128/CMR.00008-07 DISCLOSURE: The following authors have nothing to disclose: Nidhi Aggarwal, Parita Soni, Anand Kumar Rai, William Pascal, Kabu Chawla, Yizhak Kupfer No Product/Research Disclosure Information

The incidence rate of chronic lymphocytic leukemia (CLL) in the United States is approximately 0.005%; men are at slightly higher risk than women. Bony involvement or pathological fracture rarely occurs in CLL, and it may be the initial presentation. An 85-year-old woman presented with acute respiratory failure secondary to pneumonia. Symptomatology included dyspnea. She was found to have pathological fracture of the femur caused by CLL. The diagnosis of CLL had been made 6 years previously, but the patient had refused therapy. On admission, the patient required endotracheal intubation, mechanical ventilation, and admission to the medical intensive care unit. Endotracheal intubation extubation was successful after 48 hours. The patient then complained of severe left knee pain. Bone radiograph and femoral computed tomography scan revealed acute pathological fracture of the left distal femur. There was no history of trauma. The fracture was stabilized with extension lock splint. Pathological fracture in patients with CLL is associated with hypercalcemia, Richter's transformation, or multiple myeloma. This patient exemplifies the fact that pathological fracture can be caused by CLL in the absence of hypercalcemia, Richter's transformation, or multiple myeloma and can be the initial presentation of CLL.

SESSION TITLE: Diffuse Lung Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 10:45 AM - 12:00 PM INTRODUCTION: DAH is a rare, life-threatening pathology characterized by intra-alveolar hemorrhage with a spectrum of clinical presentations. This syndrome includes hemoptysis, anemia, pulmonary infiltrates and hypoxemic respiratory failure. This case is a rare presentation of DAH secondary to a Novel Oral Anticoagulant (NOAC) in the absence of systemic vasculitis. CASE PRESENTATION: An 86 year old male with past medical history of atrial fibrillation on dabigatran and congestive heart failure, was found at home, hypoxemic and bradycardic to the emergency room. The patient was also noted to be anemic, requiring 2 units of PRBC and in acute renal failure. The patient met criteria for ARDS, including a chest X-ray suggestive of bilateral diffuse pulmonary infiltrates. He was maintained on low tidal volume, high PEEP ventilator support. Bronchoscopic lavage demonstrated progressively more hemorrhagic effluent, pathognomic for DAH. Investigations for vasculitis were negative. The thrombin time was noted to be elevated and hence Idaricizumab was started and hemodialysis initiated. The patient was successfully extubated in 7 days duration. DISCUSSION: GI bleeds and intracranial hemorrhages are known complications with dabigatran, however DAH is rare with only four other cases reported in our literature review1,2. Most of these cases were prior to the advent of Idarucizumab. Dabigatran toxicity may have occurred in this patient due to the occurrence of acute renal failure. Reversal agent may have a role in treating pulmonary hemorrhage and subsequent respiratory failure secondary to the use of NOACs. Interestingly, this patient also had no prior history of vasculitides or lung disease that would predispose the patient to DAH. CONCLUSIONS: To our knowledge this is the only case where resolution of ARDS secondary to DAH by Dabigatran use was achieved with the use of Idarucizumab, hemodialysis and lung protective ventilator strategy. This highlights the importance of considering DAH as a cause of ARDS especially in the setting of anticoagulation. Increasing use of NOACs requires physicians to be aware of the adverse effects and indications for using reversal agents, when available. Reference #1: Yokoi K, Isoda K, Kimura T, Adachi T. Diffuse Alveolar Hemorrhage Associated with Dabigatran. Intern Med. 2012;51(18):2667-2668 Reference #2: Kudo, K, Tanimoto, Y, Hisamoto, A, Ichihara, E, Tanimoto, M, Kiura, K. Dabigatran etexilate-induced alveolar hemorrhage. AJRS, 1(3): 247-250, 2012. DISCLOSURE: The following authors have nothing to disclose: Shyam Shankar, Prarthna Chandar, Hatem Desoky, Ishan Malhotra, Anand Kumar Rai, Mangalore Amith Shenoy, Benhoor Shamian, Pavel Gozenput, Roman Bernstein, Pavan Irukulla, Yizhak Kupfer No Product/Research Disclosure Information