Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and is an important cause of pulmonary hypertension. As a clinical entity, it is frequently underdiagnosed with prolonged diagnostic delays. This study reviews the clinical and radiographic findings associated with CTEPH to improve awareness and recognition. Strengths and limitations of multiple imaging modalities are reviewed. Accompanying images are provided to supplement the text and provide examples of important findings for the reader.

TOPIC IMPORTANCE: Thoracic imaging with CT scan has become an essential component in the evaluation of respiratory and thoracic diseases. Providers have historically used conventional single-energy CT; however, prevalence of dual-energy CT (DECT) is increasing, and as such, it is important for thoracic physicians to recognize the utility and limitations of this technology. REVIEW FINDINGS: The technical aspects of DECT are presented, and practical approaches to using DECT are provided. Imaging at multiple energy spectra allows for postprocessing of the data and the possibility of creating multiple distinct image reconstructions based on the clinical question being asked. The data regarding utility of DECT in pulmonary vascular disorders, ventilatory defects, and thoracic oncology are presented. A pictorial essay is provided to give examples of the strengths associated with DECT. SUMMARY: DECT has been most heavily studied in chronic thromboembolic pulmonary hypertension; however, it is increasingly being used across a wide spectrum of thoracic diseases. DECT combines morphologic and functional assessments in a single imaging acquisition, providing clinicians with a powerful diagnostic tool. Its role in the evaluation and treatment of thoracic diseases will likely continue to expand in the coming years as clinicians become more experienced with the technology. CHEST 2024; 165(2):417-430

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and is an important cause of pulmonary hypertension. As a clinical entity, it is frequently underdiagnosed with prolonged diagnostic delays. This study reviews the clinical and radiographic findings associated with CTEPH to improve awareness and recognition. Strengths and limitations of multiple imaging modalities are reviewed. Accompanying images are provided to supplement the text and provide examples of important findings for the reader.

Epithelioid angiosarcoma involving the lung is a rare entity that can present with nodules or consolidations on CT imaging. We describe the case of a 23-year-old woman who presented with chronic cough and pleuritic chest pain and consolidations on CT chest who ultimately underwent diagnostic biopsy. A high index of suspicion is required for this disease, and biopsy is essential for the diagnosis of angiosarcoma. Histological evaluation and immunohistochemical analysis are helpful for the diagnosis of epithelioid angiosarcoma, and expression of CD31 is supportive of the diagnosis.

Background: The SARS-CoV2 pandemic required rapid development and expedited evaluation of vaccine efficacy. Initial evidence suggested waning immune response to SARS-CoV2 vaccination steadily over the first six months. This study evaluated duration of immunity in vaccinated patients at a single tertiary center in New York City during the pandemic. Methods: We conducted a retrospective review of adult vaccinated patients admitted over a period of 3 months during the SARS-CoV2-Omicron variant and evaluated their immune response using the spike protein antibody titer. A total of 2476 patients were screened, and 1875 patients were included in the study. Secondary analysis of a cohort of patients with COVID-19 disease was also performed. Results: Spike protein antibody was positive in 99 % of patients. Most patients received two doses of the Pfizer (42 %) or the Moderna (27 %) vaccines. There was a negative correlation between months since vaccination and spike protein antibody titer (Spearman's rank correlation –0.094, p <0.0001). Subgroup analysis of those who had received at least two doses of a vaccine series revealed similar negative correlations for both Pfizer (Spearman's rank correlation –0.14, p <0.0001) and Moderna vaccines (Spearman's rank correlation –0.11, p = 0.0043). Secondary analysis of patients admitted with a diagnosis of COVID-19 infection did not demonstrate any statistically significant difference in titer results over time. Conclusions: Our study of patients admitted to a tertiary care center across a diverse patient population demonstrated that patients who were vaccinated against SARS-COV2 had a robust response in their spike protein antibody titer which was maintained well beyond six months after vaccination.

BACKGROUND:Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality, accounting for 100,000 deaths per year in the United States. Although sex-based disparities have previously been described in this population, it is unclear if these differences have persisted with the expansion of PE evaluation and treatment approaches. The purpose of this study is to investigate sex-based differences in the evaluation, management, and outcomes of patients with acute PE. METHODS:We performed a retrospective analysis of patients enrolled in the national Pulmonary Embolism Response Team (PERT) Consortium database between October 2015 and October 2022. We evaluated patient demographics, clinical characteristics, diagnostic imaging performed, treatment at several phases of care (pre-PERT, PERT recommendations, and post-PERT), and clinical outcomes. RESULTS:A total of 5722 patients with acute PE (2838 [49.6%] women) from 35 centers were included. There were no differences in PE risk category between male and female patients. Women were less likely to undergo echocardiography (76.9% vs 73.8%) and more likely to receive no anticoagulation prior to PERT evaluation (35.5% vs 32.9%). PERT teams were more likely to recommend catheter-based interventions for men (26.6% vs 23.1%), and men were more likely to undergo these procedures (21.9% vs 19.3%). In a multivariable analysis, female sex was a predictor of in-hospital mortality (OR 1.53, 95% CI 1.06 to 2.21). CONCLUSIONS:In this analysis, we identified sex-based differences in the evaluation and management of patients presenting with acute PE. Subsequently, women presenting with acute PE were at higher risk of in-hospital mortality.

A 62-year-old woman with a history of hypertension, hypothyroidism, diabetes mellitus type 2, endometrial cancer after hysterectomy, and OSA underwent an elective total knee replacement. Her postoperative course was complicated by an esophageal food impaction requiring intubation for endoscopy, after which the patient developed postextubation bradycardia and hypoxemia in the setting of atrioventricular block and concern for flash pulmonary edema. The patient underwent a transthoracic echocardiogram, which revealed findings suggestive of acute cardiomyopathy with a negative ischemic workup. The ICU admission was complicated by recurrent left-sided atelectasis caused by mucous plugging resulting in multiple extubation failures despite aggressive pulmonary hygiene. Despite diuresis for pulmonary edema, the patient continued to report orthopnea and weak cough with inability to expectorate her sputum, and she continued to require supplemental oxygen. Further history obtained from the patient revealed progressive decline in her motor strength, worsening myalgias, and gait instability over the weeks preceding her initial admission. Neurologic examination was significant for proximal muscle weakness in the bilateral upper and lower extremities and hyperreflexia of the lower extremities. In the setting of suspected concurrent myopathy, the cardiomyopathy was attributed to myocarditis, and the patient received a permanent pacemaker for high-degree atrioventricular block. Laboratory evaluation revealed an erythrocyte sedimentation rate of 124 mm/h (normal, < 27 mm/h), C-reactive protein level of 17.7 mg/L (normal, 0-4.0 mg/L), and a creatine kinase level of 1,036 U/L (normal, 25-170 U/L). A bedside diaphragm ultrasound was performed (Videos 1, 2, 4, and 5). Question: What is the abnormality shown on the bedside diaphragm ultrasound (Videos 1 and 2 compared with Videos 4 and 5), and what is the most likely etiology of the recurrent unilateral mucous plugging and respiratory failure in this patient? Answer: The diaphragm ultrasound demonstrates weakness of the left hemidiaphragm, as evidenced by lack of exertion with both tidal and deep breathing in this patient (Videos 1 and 2), compared with a normal right hemidiaphragm (Videos 4 and 5). Use of M mode allows measurement of amplitude of excursion and calculation of diaphragm velocity, which are both markedly reduced. The bedside thoracic ultrasound is significant for unilateral left-sided diaphragmatic weakness with a large, simple pleural effusion. Based on the patient's clinical examination and history of progressive proximal muscle weakness, recent diagnosis of cardiomyopathy, and serologic evidence of muscle injury and systemic inflammation, a clinical diagnosis of inflammatory myopathy was made. Given the degree of involvement of the diaphragm and heart, the patient was empirically treated with high-dose corticosteroids and IV immunoglobulin. Results of further serologic testing revealed an antinuclear antibody titer of 1:1,280 and positive anti-Ku antibodies. The patient was ultimately diagnosed with connective tissue disease (CTD)-polymyositis overlap syndrome. Interestingly, she also developed recurrent left-sided exudative pleural effusion attributed to myositis and required placement of an indwelling pleural catheter. She had significant overall improvement in muscle weakness following initiation of therapy and was eventually titrated off supplemental oxygen therapy. Inflammatory myopathies are a heterogeneous group of CTD that can present with both muscular and extramuscular involvement. They can affect multiple organs, present in overlap syndromes, and have a wide range of severity. Myopathy in these patients with overlap syndromes may be subclinical or mild.1Tanboon J. Uruha A. Stenzel W. Nishino I. Where are we moving in the classification of idiopathic inflammatory myopathies?.Curr Opin Neurol. 2020; 33: 590-603Crossref PubMed Scopus (48) Google Scholar Pulmonary involvement in inflammatory myopathies is variable, and the frequency of involvement depends on the clinical entity. Interstitial lung disease is the most common manifestation of pulmonary involvement, although pleural and pulmonary vascular manifestations of disease have been described in the literature.2Lega J.C. Reynaud Q. Belot A. Fabien N. Durieu I. Cottin V. Idiopathic inflammatory myopathies and the lung.Eur Respir Rev. 2015; 24: 216-238Crossref PubMed Scopus (105) Google Scholar Anti-Ku antibodies are a type of myositis-associated autoantibodies implicated in multiple CTDs, including systemic sclerosis, systemic lupus erythematosus, mixed CTD, Sjogren syndrome, rheumatoid arthritis, undifferentiated CTD, and overlap syndromes.3Spielmann L. Nespola B. Severac F. et al.Anti-Ku syndrome with elevated CK and anti-Ku syndrome with anti-dsDNA are two distinct entities with different outcomes.Ann Rheum Dis. 2019; 78: 1101-1106Crossref Scopus (44) Google Scholar The presence of anti-Ku autoantibodies is most associated with undifferentiated CTD and overlap syndromes such as polymyositis, systemic sclerosis, and systemic lupus erythematosus. A higher frequency of interstitial lung disease has been observed in patients with anti-Ku autoantibodies and inflammatory myopathies-CTD. Patients with anti-Ku autoantibodies are more likely to fail to respond to corticosteroid treatments and require additional treatment with immunomodulating agents. Thus, anti-Ku autoantibodies can also be used for prognostication and prediction of treatment response. Involvement of the respiratory muscles and pleura is rare in inflammatory myopathies. Exudative pleural effusions can also occur in these patients. Although bilateral effusions may be attributable to this patient's concomitant cardiomyopathy, the exudative nature of the effusion suggests that the fluid may be inflammatory in nature. Moreover, the left-sided effusion was larger and rapidly reaccumulated, suggestive of an inflammatory cause for the effusion that correlates with left hemidiaphragm weakness. Cardiac involvement in dermatomyositis and polymyositis has been described, with an estimated prevalence between 9% and 72%.4Zhang L. Wang G.C. Ma L. Zu N. Cardiac involvement in adult polymyositis or dermatomyositis: a systematic review.Clin Cardiol. 2012; 35: 686-691PubMed Google Scholar Congestive heart failure due to left ventricular dysfunction is the most common clinical presentation and may result in pulmonary edema. Myocarditis can also occur and typically presents in conjunction with active muscular disease. Patients may also develop significant conduction blocks, supraventricular arrhythmias, or ventricular arrhythmias. Cardiac involvement in polymyositis and dermatomyositis has been reported as a poor prognostic factor, with increased mortality in both the acute and recovery phases of treatment. Ultrasound is a powerful tool for diagnosing underlying causes of respiratory failure through evaluation of the thoracic and cardiac systems. This evaluation begins with the phased array probe on the anterior chest, noting an A-line or B-line pattern. The phased array probe is next moved to the posterolateral alveolar and/or pleural syndrome (PLAPS) point.5Lichtenstein D.A. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.Chest. 2015; 147: 1659-1670Abstract Full Text Full Text PDF PubMed Scopus (356) Google Scholar At the PLAPS point, the diaphragm is noted on the right portion of the image with the lung located to the left of the image. The PLAPS point is where many pulmonary pathologies such as effusions, consolidations, and/or diaphragmatic dysfunction can be observed. Following completion of the lung ultrasound, a cardiac ultrasound is performed at the parasternal long axis, parasternal short axis, apical four chamber, and subcostal with inferior vena cava views. This combined lung and cardiac ultrasound can lead to more rapid diagnosis and treatment of etiology of respiratory failure in the critically ill with greater accuracy than traditional methodologies.6Wang X. Liu D. He H. et al.Using critical care chest ultrasonic examination in emergency consultation: a pilot study.Ultrasound Med Biol. 2015; 41: 401-406Abstract Full Text Full Text PDF PubMed Google Scholar Diaphragmatic function can be analyzed with ultrasound using both the B and M modes and either the phased or linear array transducers. Global evaluation of diaphragmatic excursion is usually screened at the PLAPS point by using the phased array transducer. A normally functioning diaphragm will contract with respiration, a term called diaphragmatic excursion. In this patient, there is reduction in diaphragmatic excursion on the left during tidal breathing (Video 1), and this reduction in diaphragmatic excursion persists during deep inspiration (Video 2). In contrast, there is normal diaphragmatic excursion on the right (Video 4). Diaphragmatic thickness is measured at end-inspiration and at end-expiration. The accepted lower limit of normal at end-expiration for diaphragmatic thickness is 1.3 mm in men and 1.1 mm in women.7Boussuges A. Rives S. Finance J. et al.Ultrasound assessment of diaphragm thickness and thickening: reference values and limits of normality when in a seated position.Front Med (Lausanne). 2021; 8742703Google Scholar M-mode evaluation of the diaphragm allows for measurement of thickness during the phases of respiration and calculation of velocity of contraction. Velocity of contraction is calculated as excursion of the diaphragm divided by the time to reach maximal excursion.8Turton P. Aidarous S.A.L. Welters I. A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading?.Ultrasound J. 2019; 11: 2Crossref Scopus (24) Google Scholar In this patient, M-mode evaluation of the diaphragm allows measurement of velocity of contraction at 4.0 cm per second on the left (Video 1, Part 2). In comparison, use of M mode on the right diaphragm allows measurement of velocity of contraction at 6.3 cm per second (Video 4, Part 2). A more detailed evaluation of diaphragmatic anatomy and function can be assessed by using the linear array transducer. The linear transducer is a higher-frequency transducer and is therefore ideal for a focused evaluation of diaphragm function. Higher resolution imaging permits measurement of thickness and function using both B and M modes. Grossly, B mode using the linear transducer demonstrates lack of movement of the left diaphragm (Video 3) compared with the right diaphragm (Video 5). Percent change in diaphragmatic thickness, or thickening fraction, is a described method to evaluate diaphragmatic function.9McCool F.D. Oyieng'o D.O. Koo P. The utility of diaphragm ultrasound in reducing time to extubation.Lung. 2020; 198: 499-505Crossref PubMed Scopus (9) Google Scholar Thickening fraction is calculated as end-inspiration thickness minus end-expiration thickness divided by the end-expiration thickness multiplied by 100. A thickening fraction < 20% to 30% is concerning for significant diaphragmatic dysfunction. M-mode evaluation of the diaphragm allows for measurement of thickness during the phases of respiration. Measurement of diaphragmatic thickness on the left (Video 3, Part 2) using M mode reveals a thickening fraction of 7.5, which was significantly reduced compared with the right (not shown). For the current study patient, a unifying diagnosis of inflammatory myositis was made in the presence of diaphragmatic weakness, recurrent inflammatory pleural effusion, cardiomyopathy, and proximal muscle weakness. The prognosis following initiation of therapy is favorable in these patients. Most patients have improvement or recovery of respiratory muscle function, as reported in longitudinal follow-up of a case series of patients with polymyositis/dermatomyositis.10Selva-O'Callaghan A. Labrador-Horrillo M. Munoz-Gall X. et al.Polymyositis/dermatomyositis-associated lung disease: analysis of a series of 81 patients.Lupus. 2005; 14: 534-542Crossref PubMed Scopus (0) Google Scholar Use of ultrasonography has a role in the identification of diaphragmatic weakness or paralysis and may be an important finding in critically ill patients. See Narration Video for a detailed explanation of Videos 1-5. 1.Use of ultrasonography to evaluate diaphragmatic function can be performed quickly at the bedside and allows for early recognition of diaphragmatic weakness or paralysis, which is underdiagnosed due to its nonspecific presentation.2.In patients with acute respiratory failure and evidence of inflammatory myopathies, evaluation of the diaphragmatic function may reveal weakness of the respiratory muscles.3.Point-of-care echocardiography can reveal evidence of cardiac involvement in inflammatory myopathies, a finding that has both treatment and prognostic implications. None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: Videos for this case are available under "Supplementary Data." eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxNzFhMjk3ZWRiZWExZTM2NTZiMGQwMWE0NmQzNjk4NSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.mqhaqbtdlIN8t7ou7-VSxMBiUV1W_9DZcGoCl2sD34K-LF7MF_s1iIx3ElcRJRa1BjgwVXlednl3sqRw4E-Yi_lSgLI-5dtRUVRnteTSz8GqR2PB7lKDEvvfdARSYZWz-WfBMT5LYRiXTroL1gDm_tR2y6yTiLpv1YETmFtyRkMhWY1-UUsl7UaTMY_QShMBUXq7doO5L_7YdW4-x6jwPXyH0g_2xZL0RAdAAlqiRdKNenZHb2qMO42YNBPNLkp_7_gKJlH0X3UASYOJzE1ID5L0h6xwoxlO6jDHD6OzIWeUGzfJQ-sdXW86KMyAwXBqf2x0OBpW_Q83Wj6KjvU8rQ Download .mp4 (63.68 MB) Help with .mp4 files Video 1Left diaphragm tidal breathing. Part 1: The diaphragm ultrasound demonstrates significant weakness of the left hemidiaphragm, as evidenced by lack of excursion during normal breathing. Part 2: Use of M-mode through the left diaphragm allows for measurement of diaphragm velocity (A) equaling 4.0 cm per second.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjYjVjYjkxZDkzNjdjMWExNjNlZjZmNDZmNTcyYmY0ZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.FsTqccRCc7Adg1bUPvD4vKOc8IAeuwnyUkpgZVUwdaA2fb7htECKr7PoeymOm2DV2aSNHdjBooby7qqI94rdl15RVa6dKZ1MU-9UbCsx6gz9J9Mb_ZcjSsSq-_LtZBtzCmZ6C8j1QdxdqXZGwi2Dx8POjlOnDloLrpnsrwhnapTiGK4Q0jpSwhkElWHELSSyOcaWXCuKVe6_LdJwn5w7q7W7XUSAbJYJV7zw-S3bAJM7Q3xetjL1EJxZhzLAk6WGxxu0SZbRsT9koJz9pLITRBp-E8RTrYG4ICjJA_AWxm2Cj7uhbH4s2wpDlLkNybTnCmLs5w2RKEdAauB2E80WAQ Download .mp4 (5.65 MB) Help with .mp4 files Video 2Left diaphragm deep breathing. The diaphragm ultrasound demonstrates weakness of the left hemidiaphragm with lack of excursion during deep breathing. Also visualized are the spleen, left kidney, and left ventricular cardiac contraction.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzOWE2Y2QwZjVjMjJiZDRlYzE5ZGZkMTBmZDIzNzFiZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.akxunLWaaMbtCTciMzO-3AZiVIWFYb_vSRd4ku4b2aeaQSljoiLnJNuxgTy2GxEKKAU4ut9gPRqHLcZEPcJFOdIblad4On4gvXMZNo431TxWtpJIz9eidzl7FlrOquf54Y6gNlqmqcXKfr6YMMIGuweOFjUZ2lIH_cOyOsXVEqURHLFUpkP_yAJSneIBTcKOTcz4xZ2joY78e7wfKxkL0DmjChD0FczI_tVZyiCOSquWcLgMmQ_5A5aZb3vlt_puRwE4T58zC9q93H4WRrbJxuSdFjrqAWvUbzJem961a3BVHifuY_UYLGTwl-aR4SAmosbfPFf2ujCz38wX5xJEGA Download .mp4 (1.01 MB) Help with .mp4 files Video 3Left diaphragm detailed view and M mode. Part 1: Ultrasound of the left diaphragm demonstrates the presence of three distinct layers, with two echogenic layers of peritoneum and pleura on either side of the hypoechoic layer of muscle within. Again demonstrated is a lack of excursion with breathing. Part 2: Use of M mode through the left diaphragm allows for measurement of diaphragmatic thickness and determination of change of thickness during inspiration (A) and expiration (B). As shown, diaphragmatic thickness is noted to be 0.57 cm at end-inspiration and 0.53 cm at end-expiration, demonstrating no respiratory variation.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ZTRkNmU1NzhlNGZkNzUwMzk0M2IwYzhkZmFmNzJlZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.DfbZ33-VBQH10u7iaALozrDggFN1n8Hqpiao9CDd5Lmx0bCNl3EA6YsUxeLAcUpMVeEqUxdXSb7GoxP_QNsqPXYWPpQuN-ozXgGxWznRSYpRK-QudGrUCOUPZVAS7Dz2A-yjamr91irBrPBsiOH25RBRF7mftSfS6PL4d5Q2f-C3ujO2-tf5qgv0IEW5P240OD49KC4lNyc-XrKF0e6vkYIaV_iAxgMVKvRo_8ht3klnbXemNvUnUMQKRW2c5vAfF9ILx6KjGZSgZlSOIOKlxgZXKLZL4Z5va2X7YzO_GUbIpnmFJm4MWFZAIUC8lIQicxU_ZyBkZRqaIh5-RV48UA Download .mp4 (0.99 MB) Help with .mp4 files Video 4Right diaphragm tidal breathing. Part 1: Right hemithorax ultrasound demonstrates the presence of a moderate, simple pleural effusion with consolidated lung and normal diaphragmatic excursion with passive respiration. Part 2: Use of M mode through the right diaphragm allows for measurement of diaphragm velocity (A) equaling 6.3 cm per second.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ODM0YzMxOTJhZjlmNDY3NThkODhjZDg4MzQxM2ZkYiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.lro37NZx8cSnAC3DISCnV2oS21J58hZbvaxEfvAiqScVCvuuf7xewP4ZHCvo9VwN2hB3PDmhaB5CxLEMMFi0nVY59jsPt8-_EWvbIa8I8av_Or_71Ec7jhxgsGrqVQTyZt73lK7DHcyeCnbJw1UFxlXy5Oc_SNBtZJZzay2Ut4V3gZ53aXszs5h2Eo4rSK9r6-Px6No6qo2J1TXXOUe7TL29dbsDD2x4WuGpYvwZKjt-a1Twd_JeiRzno3z934kMNWOFOUahIBdnAcYBPJtwmpyCHs-U43L2p1W9coN1Jg63dj-ip8orKUtvyfdR6Py7fi8BE-0WywsAUDvlF7mgDQ Download .mp4 (2.01 MB) Help with .mp4 files Video 5Right diaphragm detailed view. Contrast this video with Video 3. Ultrasound of the right diaphragm demonstrates again the presence of two echogenic layers with a central hypoechoic layer of muscle within and clear excursion of the diaphragm with passive breathing.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkNTRjZTA4MTgyYTVkNTg2NTg4NTExM2UxNWE3ZmRjNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MjM0MTM2fQ.h-yCvNNFWFv9IarwWB7wgRUgM-lmObHOpEGsJplzM_t8c5tH3MZrugaQwUOSSyyoXJxJnrv-g5RwVokIG-GQAcRWkD2KIl4H02PkkpuejWN42db6-kgZs57WQeWQM92P4cXwt-qetKcS1cSWgjA15UFTxPy4249INvRnCQBIZA-eAPKAuyQ1Ms_wobeqC2k7BLRejSOeD3SmgTq2HnVQnl6KDYb9erNdcXGrU8TPgEJiLArnrgOJ5Yk3epeNAjrKurZSyS6HuOA31PaW2FnQypzi1JSB27ZlIhOBgiGfGe-ZCRPfvqoriIQnyHLuYctjV5ie3qfnGwJxXhGdwsIM3A Download .mp4 (1.06 MB) Help with .mp4 files Video 6Discussion video.

CASE PRESENTATION: A 53-year-old woman with a history of pulmonary embolism treated with rivaroxaban came to the ED after 4 days of acutely worsening dyspnea and chest pressure. On arrival, her temperature was 36.7 degrees C; heart rate, 71 beats/min; BP, 98/ 59 mm Hg; respiratory rate, 22 breaths/min; and SpO2 95% on room air. Her WBC count was elevated at 15,770/mL; hemoglobin, 13.3 g/dL; platelets, 280,000/mL; INR (international normalized ratio), elevated at 1.66; and partial thromboplastin time, elevated at 18.8 s. Serum chemistry results were unremarkable, and pro-brain natriuretic peptide was slightly elevated at 530 pg/mL (normal, < 300 pg/mL).

INTRODUCTION: Point of care ultrasound (POCUS) is a useful adjunct tool in the intensive care unit and has become standard of care in evaluating and managing critically ill patients.Several protocols exist to guide the use of abdominal ultrasonography.We describe a case of retroperitoneal bleed which was diagnosed by bedside abdominal ultrasound in a patient with shock. CASE PRESENTATION:A 58-year-old woman with history of hypertension, osteoarthritis and stage 3 breast cancer of the left breast, presented with two days of left arm pain and extremity weakness.Her breast cancer was previously treated with lumpectomy, lymph node excision, and radiation, and she was on chemotherapy with capecitabine and pembrolizumab.The patient noted progressive upper and lower extremity weakness.After extensive workup including imaging and lumbar puncture, she was diagnosed with Guillain-Barre Syndrome secondary to pembrolizumab use.The patient was treated with steroids and plasmapheresis with improvement in her neurologic symptoms.Her hospital course was complicated by tachycardia, hypotension, and altered mental status associated with a drop in hemoglobin from 10.9 to 8.1 g/dL.Bedside point of care ultrasound performed revealed an anechoic structure and septations within a collection of fluid in the suprapubic area (Figure 1A-B) and evidence of moderate right-sided hydronephrosis (Figure 1C).The patient was managed with fluid resuscitation, packed red blood cell transfusion, protamine for heparin reversal, and vasopressors for support of hemorrhagic shock.CT abdomen and pelvis confirmed the presence of a large intrapelvic hematoma, two sites of active bleeding, and layering of intraperitoneal free fluid (Figure 2).Interventional radiology performed coiling of the bilateral epigastric arteries.The patient was ultimately restarted and monitored on anticoagulation and discharged to a rehabilitation facility.DISCUSSION: Evaluation of bilateral kidneys is incorporated in the typical intensive care unit POCUS and can suggest diagnoses such as hydronephrosis, as was seen in this case.Evaluation of these spaces can allow for visualization of other entities such as abscesses or fluid collections.Though the retroperitoneal space is not usually evaluated in the abdominal ultrasound examination, this case suggests the utility of ultrasound in making the diagnosis of retroperitoneal bleed quickly in the patient with shock.One case report of a spontaneous retroperitoneal bleed suggests utility for a modified RUSH protocol which incorporates abdominal POCUS into the RUSH exam.The authors extended the POCUS by examining the posterolateral thoracoabdominal junction zone.Ultimately, further imaging of the abdomen and pelvis confirms the diagnosis.However, the use of abdominal POCUS provides insight into the suspected diagnosis and allows for early resuscitation and transfusion in patients with hemorrhagic shock.This is especially useful in patients who are too critically ill to transport for imaging.CONCLUSIONS: Abdominal ultrasound is an integral part of POCUS in the intensive care unit to evaluate for intra-abdominal etiologies of shock, and use of POCUS can be utilized for the diagnosis of retroperitoneal bleed quickly.

Lung adenocarcinoma (LUAD) is known to display morphological and genomic diversity, both spatially and temporally. However, the genomic underpinnings of the spatiotemporal intra-tumour heterogeneity of growth patterns remain unclear.

SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Listeria monocytogenes is a gram-positive bacterium associated with contaminated foods. Severe disease is typically seen in individuals at the extremes of age, immunosuppressed individuals, and pregnant women. Clinical manifestations vary depending upon a patient's immunological status and bacterial inoculum. We report the case of a 46 year old immunocompetent male who developed neurolisteriosis and bacteremia. CASE PRESENTATION: A 46-year-old male presented with a chief complaint of worsening diarrhea and headache for 3 days. He noted fever, chills, confusion, and lethargy. Past medical history was pertinent for well controlled type 2 diabetes mellitus and quiescent psoriasis. He had recently returned from vacation in Peru where he had undergone a root canal procedure. In the ER, vital signs were notable for a temperature of 104.9F. Labs were significant for leukocytosis and a mildly elevated ESR and CRP. Computed tomography of the head revealed heterogeneous attenuation in the left basal ganglia and left inferior frontal lobe with vasogenic edema - raising concerns for possible cerebritis or abscess. He was started on vancomycin, cefepime and metronidazole given history of recent dental procedure and a low volume lumbar puncture was performed. CSF PCR was positive for Listeria and blood cultures subsequently grew the same. He was started on ampicillin and gentamycin for neurolisteriosis with significant clinical improvement. He was discharged home to complete a total of 6 weeks of antibiotics. DISCUSSION: Typical symptoms of Listeria are gastrointestinal. Patients with invasive listeriosis may develop sepsis, meningitis, or meningoencephalitis. The mean incubation period for invasive listeriosis is 11 days and 90% of cases will present within 28 days of exposure. Patients with bacteremia typically present with fever and have antecedent diarrhea, bacterial seeding of the CNS may occur. The majority of cases of neurolisteriosis manifest as meningoencephalitis (84%) with few developing cerebritis (2%). This patient was immunocompetent and had no clear identifiable exposure to Listeria making his case highly atypical. Empiric treatment of listeria is recommended in patients with clinical signs of meningitis and one of the following: immunocompromised, infants less than 1 month, or patients over 50 years old. Three month mortality in patients with neurolisteriosis is high (30%), prompt diagnosis and treatment is essential. CONCLUSIONS: Listeria monocytogenes infections are a common cause of food borne illness and frequently present with gastrointestinal symptoms. Severe invasive disease may occur in select patients. Neurolisteriosis has rarely been reported in immunocompetent hosts. Patients with neurologic involvement and antecedent diarrhea should be evaluated for Listeria and empiric treatment may be considered given high mortality associated with neurolisteriosis. Reference #1: Charlier C, Perrodeau É, Leclercq A, Cazenave B, Pilmis B, Henry B, Lopes A, Maury MM, Moura A, Goffinet F, Dieye HB, Thouvenot P, Ungeheuer MN, Tourdjman M, Goulet V, de Valk H, Lortholary O, Ravaud P, Lecuit M; MONALISA study group. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. Lancet Infect Dis. 2017 May;17(5):510-519. doi: 10.1016/S1473-3099(16)30521-7. Epub 2017 Jan 28. Erratum in: Lancet Infect Dis. 2017 Sep;17(9):897. PMID: 28139432. Reference #2: Angelo KM, Jackson KA, Wong KK, Hoekstra RM, Jackson BR. Assessment of the Incubation Period for Invasive Listeriosis. Clin Infect Dis. 2016 Dec 1;63(11):1487-1489. doi: 10.1093/cid/ciw569. Epub 2016 Aug 17. PMID: 27535950; PMCID: PMC5421300. DISCLOSURES: No relevant relationships by Erica Altschul No relevant relationships by Katherine Andrade No relevant relationships by Akhilesh Mahajan No relevant relationships by Jonathan Moore

Introduction Treatment with dexamethasone reduces mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia requiring supplemental oxygen, but the optimal dose has not been determined. Objective To determine whether weight-based dexamethasone of 0.2 mg/kg is superior to 6 mg daily in reducing 28-day mortality in patients with COVID-19 and hypoxemia. Materials and methods A multicenter, open-label, randomized clinical trial was conducted between March 2021 and December 2021 at seven hospitals within Northwell Health. A total of 142 patients with confirmed COVID-19 and hypoxemia were included. Participants were randomized in a 1:1 ratio to dexamethasone 0.2 mg/kg intravenously daily (n = 70) or 6 mg daily (n = 72) for up to 10 days. Results There was no statistically significant difference in the primary outcome of 28-day all-cause mortality with deaths in 12 of 70 patients (17.14%) in the intervention group and 15 of 72 patients (20.83%) in the control group (p = 0.58). There were no statistically significant differences among the secondary outcomes. Conclusion In patients with COVID-19 and hypoxemia, the use of weight-based dexamethasone dosing was not superior to dexamethasone 6 mg in reducing all-cause mortality at 28 days. Clinical trial registration This study was registered under ClinicalTrials.gov (identifier: NCT04834375).

SESSION TITLE: Chest Infections in Immunocompromised Patients Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Aspergillus species exist ubiquitously in the environment, and clinical sequelae generally occur after inhalation of spores. Invasive Pulmonary Aspergillosis (IPA) is characterized by culture-positive Aspergillus species and tissue invasion with hyphae on histopathological exam, and the most relevant risk factor is immunosuppression (particularly neutropenia). IPA can manifest with nonspecific pulmonary symptoms including fever, shortness of breath, pleuritic chest pain, and hemoptysis.CASE PRESENTATION: A 39-year-old man with AIDS, stage IV Hodgkin's lymphoma, and active IV drug use presented with decreased mentation, septic shock and profound pancytopenia and was diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). His course was complicated by intermittent epistaxis, hemoptysis, and persistent fevers. Computed tomography (CT) chest performed at that time revealed scattered areas of ground glass opacities (Figure 1) in the setting of nosocomial rhinovirus. One month later, a repeat CT chest was performed due to persistent cough (Figure 2). During this interval one month period, peak serum Fungitell level was >500 pg/mL (N <80 pg/mL). A bronchial alveolar lavage (BAL) culture grew Aspergillus flavus, and the patient was started on voriconazole. After several weeks, patient had complete resolution of symptoms, and repeat CT chest showed interval decrease in the size of the mycetomas.DISCUSSION: Diagnosis of IPA requires characteristic mycologic identification, clinical context, and imaging features.3 Characteristic CT chest findings including dense, well-circumscribed lesions, air-crescent sign, cavitary lesions, or mycetomata (Figure 2). Clinical features also include the presence of a persistent pulmonary infection despite broad-spectrum antibiotics. Mycological evidence includes detection of Aspergillus species in sputum, BAL, bronchial brush, or bronchial aspirate; galactomannan antigen detection in plasma, serum, or BAL. In this case, bronchoscopy was performed with unremarkable cell count-BAL fungal cultures identified Aspergillus flavus. In the context of recent neutropenia, recognized hematologic malignancy, cavitary lung nodules, ICU admission, and Aspergillus species detected on BAL culture, the diagnosis of IPA was definitive.CONCLUSIONS: Our patient presented atypically with rapid progression of cavitary pulmonary nodules over one month in the context of active malignancy and secondary HLH. In patients with suspected IPA, bronchoscopy is a useful diagnostic tool and can rule out concurrent infectious processes.Reference #1: Patterson TF, Thompson GR, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63 (4), e1-e60.Reference #2: Kosmidis C and Denning DW. The Clinical Spectrum of Pulmonary Aspergillosis. Thorax 2015; 70: 270-277.Reference #3: Russo A, Tiseo G, Falcone M et al. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9: 511-524.DISCLOSURES: No relevant relationships by Zein KattihNo relevant relationships by Simon MeredithNo relevant relationships by Jonathan MooreNo relevant relationships by Margarita OksNo relevant relationships by Sean Zajac SESSION TITLE: Chest Infections in Immunocompromised Patients Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Aspergillus species exist ubiquitously in the environment, and clinical sequelae generally occur after inhalation of spores. Invasive Pulmonary Aspergillosis (IPA) is characterized by culture-positive Aspergillus species and tissue invasion with hyphae on histopathological exam, and the most relevant risk factor is immunosuppression (particularly neutropenia). IPA can manifest with nonspecific pulmonary symptoms including fever, shortness of breath, pleuritic chest pain, and hemoptysis. CASE PRESENTATION: A 39-year-old man with AIDS, stage IV Hodgkin's lymphoma, and active IV drug use presented with decreased mentation, septic shock and profound pancytopenia and was diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). His course was complicated by intermittent epistaxis, hemoptysis, and persistent fevers. Computed tomography (CT) chest performed at that time revealed scattered areas of ground glass opacities (Figure 1) in the setting of nosocomial rhinovirus. One month later, a repeat CT chest was performed due to persistent cough (Figure 2). During this interval one month period, peak serum Fungitell level was >500 pg/mL (N <80 pg/mL). A bronchial alveolar lavage (BAL) culture grew Aspergillus flavus, and the patient was started on voriconazole. After several weeks, patient had complete resolution of symptoms, and repeat CT chest showed interval decrease in the size of the mycetomas. DISCUSSION: Diagnosis of IPA requires characteristic mycologic identification, clinical context, and imaging features.3 Characteristic CT chest findings including dense, well-circumscribed lesions, air-crescent sign, cavitary lesions, or mycetomata (Figure 2). Clinical features also include the presence of a persistent pulmonary infection despite broad-spectrum antibiotics. Mycological evidence includes detection of Aspergillus species in sputum, BAL, bronchial brush, or bronchial aspirate; galactomannan antigen detection in plasma, serum, or BAL. In this case, bronchoscopy was performed with unremarkable cell count-BAL fungal cultures identified Aspergillus flavus. In the context of recent neutropenia, recognized hematologic malignancy, cavitary lung nodules, ICU admission, and Aspergillus species detected on BAL culture, the diagnosis of IPA was definitive. CONCLUSIONS: Our patient presented atypically with rapid progression of cavitary pulmonary nodules over one month in the context of active malignancy and secondary HLH. In patients with suspected IPA, bronchoscopy is a useful diagnostic tool and can rule out concurrent infectious processes. Reference #1: Patterson TF, Thompson GR, Denning DW et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63 (4), e1-e60. Reference #2: Kosmidis C and Denning DW. The Clinical Spectrum of Pulmonary Aspergillosis. Thorax 2015; 70: 270-277. Reference #3: Russo A, Tiseo G, Falcone M et al. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9: 511-524. DISCLOSURES: No relevant relationships by Zein Kattih No relevant relationships by Simon Meredith No relevant relationships by Jonathan Moore No relevant relationships by Margarita Oks No relevant relationships by Sean Zajac

SESSION TITLE: Bedside Ultrasound Cases: Beyond Our SightSESSION TYPE: Case ReportsPRESENTED ON: 10/19/2022 09:15 am - 10:15 amINTRODUCTION: The presentation of massive pulmonary embolism is variable and can include development of right heart strain and, ultimately, cardiac collapse and arrest. Presentation of a clot-in-transit in particular carries high risk, and it is rare to visualize these clots immediately before cardiac decompensation. We present a rare case of clot-in-transit identified on echocardiography in a patient who subsequently has a cardiac arrest and return of spontaneous circulation after systemic thrombolysis.CASE PRESENTATION: A 40-year-old man present after syncopal episode on the street, where bystanders called emergency medical services. The patient reported 3 weeks of progressive dyspnea on exertion that eventually limited his ability to ambulate. On presentation, the patient had a heart rate of 110 beats per minute, blood pressure of 93/60 mmHg, and he was neither febrile nor hypoxic. The patient's lactate was notably elevated to 3.3 mmol/L, troponin was elevated to 0.312 ng/mL, and pro-brain natriuretic peptide was elevated to 2550 pg/mL. The patient underwent a CT angiography of the chest which demonstrated extensive bilateral lobal and segmental pulmonary emboli with evidence of right heart strain. Echocardiography demonstrated right atrial dilation, tricuspid annual plane systolic excursion (TAPSE) of 15 mmHg, and pulmonary artery systolic pressure (PASP) 82 mmHg. Echocardiography also demonstrated a large, mobile multilobulated echogenic structures in the right atrium that prolapse into the right ventricle during diastole. The patient was transferred to the intensive care unit for monitoring and acutely decompensated with tachycardia, tachypnea, and desaturation followed by PEA arrest. The patient received 10 minutes of CPR, was intubated for airway protection, and had return of spontaneous circulation (ROSC) after 10 minutes. He was then started on pressors and inhaled nitric oxide. The patient's hemodynamic profile improved, he was extubated after 3 days, and eventually discharged on oral anticoagulation.DISCUSSION: This patient presented with syncope in the setting of massive pulmonary embolism and hemodynamic instability. Extensive pulmonary emboli were seen on CT imaging, and echocardiography demonstrated evidence of right heart strain and a clot-in-transit. The etiology of his cardiac collapse in this setting was clear, and treatment with systemic thrombolysis allowed for ROSC and eventual recovery.CONCLUSIONS: Pulmonary embolism, particularly intermediate- and high-risk pulmonary embolism, requires risk stratification using echocardiography, cardiac enzymes, and hemodynamic monitoring to allow for early recognition of decompensation and advanced intervention if needed.Reference #1: Konstantinides SV, Meyer G, Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41(4): 543-603.DISCLOSURES: No relevant relationships by Brenda GarciaNo relevant relationships by Zein KattihNo relevant relationships by Bushra MinaNo relevant relationships by Jonathan Moore SESSION TITLE: Bedside Ultrasound Cases: Beyond Our Sight SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: The presentation of massive pulmonary embolism is variable and can include development of right heart strain and, ultimately, cardiac collapse and arrest. Presentation of a clot-in-transit in particular carries high risk, and it is rare to visualize these clots immediately before cardiac decompensation. We present a rare case of clot-in-transit identified on echocardiography in a patient who subsequently has a cardiac arrest and return of spontaneous circulation after systemic thrombolysis. CASE PRESENTATION: A 40-year-old man present after syncopal episode on the street, where bystanders called emergency medical services. The patient reported 3 weeks of progressive dyspnea on exertion that eventually limited his ability to ambulate. On presentation, the patient had a heart rate of 110 beats per minute, blood pressure of 93/60 mmHg, and he was neither febrile nor hypoxic. The patient's lactate was notably elevated to 3.3 mmol/L, troponin was elevated to 0.312 ng/mL, and pro-brain natriuretic peptide was elevated to 2550 pg/mL. The patient underwent a CT angiography of the chest which demonstrated extensive bilateral lobal and segmental pulmonary emboli with evidence of right heart strain. Echocardiography demonstrated right atrial dilation, tricuspid annual plane systolic excursion (TAPSE) of 15 mmHg, and pulmonary artery systolic pressure (PASP) 82 mmHg. Echocardiography also demonstrated a large, mobile multilobulated echogenic structures in the right atrium that prolapse into the right ventricle during diastole. The patient was transferred to the intensive care unit for monitoring and acutely decompensated with tachycardia, tachypnea, and desaturation followed by PEA arrest. The patient received 10 minutes of CPR, was intubated for airway protection, and had return of spontaneous circulation (ROSC) after 10 minutes. He was then started on pressors and inhaled nitric oxide. The patient's hemodynamic profile improved, he was extubated after 3 days, and eventually discharged on oral anticoagulation. DISCUSSION: This patient presented with syncope in the setting of massive pulmonary embolism and hemodynamic instability. Extensive pulmonary emboli were seen on CT imaging, and echocardiography demonstrated evidence of right heart strain and a clot-in-transit. The etiology of his cardiac collapse in this setting was clear, and treatment with systemic thrombolysis allowed for ROSC and eventual recovery. CONCLUSIONS: Pulmonary embolism, particularly intermediate- and high-risk pulmonary embolism, requires risk stratification using echocardiography, cardiac enzymes, and hemodynamic monitoring to allow for early recognition of decompensation and advanced intervention if needed. Reference #1: Konstantinides SV, Meyer G, Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41(4): 543-603. DISCLOSURES: No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Bushra Mina No relevant relationships by Jonathan Moore

BACKGROUND: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) continues to be a global challenge due to the lack of definitive treatment strategies. We sought to determine the efficacy of early administration of anti-interleukin 6 therapy in reducing hospital mortality and progression to mechanical ventilation. METHODS: This was a retrospective chart review of 11,512 patients infected with SARS-CoV-2 who were admitted to a New York health system from March to May 2020. Tocilizumab was administered to subjects at the nasal cannula level of oxygen support to maintain an oxygen saturation of >88%. The Charlson comorbidity index was used as an objective assessment of the burden of comorbidities to predict 10-year mortality. The primary outcome of interest was hospital mortality. Secondary outcomes were progression to mechanical ventilation; the prevalence of venous thromboembolism and renal failure; and the change in C-reactive protein, D-dimer, and ferritin levels after tocilizumab administration. Propensity score matching by using a 1:2 protocol was used to match the tocilizumab and non-tocilizumab groups to minimize selection bias. The groups were matched on baseline demographic characteristics, including age, sex, and body mass index; Charlson comorbidity index score; laboratory markers, including ferritin, D-dimer, lactate dehydrogenase, and C-reactive protein values; and the maximum oxygen requirement at the time of tocilizumab administration. Mortality outcomes were evaluated based on the level of oxygen requirement and the day of hospitalization at the time of tocilizumab administration. RESULTS: The overall hospital mortality was significantly reduced in the tocilizumab group when tocilizumab was administered at the nasal cannula level (10.4% vs 22.0%; P = .002). In subjects who received tocilizumab at the nasal cannula level, the progression to mechanical ventilation was reduced versus subjects who were initially on higher levels of oxygen support (6.3% vs 18.7%; P < .001). There was no improvement in mortality when tocilizumab was given at the time of requiring non-rebreather, high-flow nasal cannula, noninvasive ventilator, or invasive ventilator. CONCLUSIONS: Early use of anti-interleukin 6 therapy may be associated with improved hospital mortality and reduction in progression to more severe coronavirus disease 2019.

SESSION TITLE: Cardiothoracic Interventions 1 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Tetralogy of fallot (TOF) is a congenital syndrome characterized classically by four cardiac defects including right ventricular outflow tract obstruction (RVOT), ventricular septal defect (VSD), overriding aorta and concentric RV hypertrophy. The prevalence in the United States is approximately 4-5 per 10,000 live births. TOF usually occurs sporadically and without other anomalies. We present an adult patient with unrepaired TOF who presented with massive pulmonary artery dilatation. CASE PRESENTATION: A 63-year-old female with a history of unrepaired TOF, atrial fibrillation and a 30 pack-year smoking history was admitted for decompensated heart failure with reduced ejection fraction (HFrEF). Her labs were notable for significant polycythemia (Hgb 18.3 g/dL). A CT of the chest was performed and showed massive pulmonary artery dilatation – left (70 mm) greater than right (55mm) – and evidence of HFrEF. Transthoracic echocardiogram (TTE) showed severely reduced biventricular function, a perimembranous VSD, severe pulmonic valve stenosis, severely dilated main pulmonary artery, and severely dilated right ventricle. The RV EF was 20% by cardiac MRI. Cardiac catheterization was performed and was significant for non-restrictive VSD, normal pulmonary pressures, a gradient of 90 mmHg across the pulmonary valve and normal coronary anatomy. Qp:Qs was 1.7, consistent with left-to-right shunting. The patient was evaluated for transplant and, after multidisciplinary discussion, the patient underwent VSD patch closure, transannular patch, pulmonary valve replacement and atrial septostomy. At follow up, TTE was notable for improvement in biventricular dilatation, mild improvement in biventricular function, and overall improvement in her symptoms. DISCUSSION: The presentation of TOF at birth is variable and depends on the degree of RVOT obstruction. TOF is the most common cyanotic congenital heart disease to reach adulthood without surgical repair. However, less than 5% of patients survive past 30. Our patient’s prolonged survival is due to acyanotic nature of her TOF. Our patient’s condition was complicated by massive aneurysmal dilatation of the pulmonary arteries due to long standing pulmonic valve stenosis. Her polycythemia at presentation was significant and secondary to chronic hypoxemia from right-to-left shunting through her VSD. Flow across the shunt is dynamic; at rest she had significant left-to-right shunting but exertion she develops significant hypoxemia likely due to reversal of the shunt. Common causes of morbidity and mortality in adult survivors of TOF include arrhythmia, congestive heart failure, and sudden cardiac death. CONCLUSIONS: Morbidity and mortality for TOF is improving and many patients are living into adulthood. Physiology is complex and variable between patients. Adult providers must be familiar with the syndrome and long-term morbidity associated with TOF. Reference #1: Abraham KA, Cherian G, Rao VD, Sukumar IP, Krishnaswami S, John S. Tetralogy of Fallot in adults. A report on 147 patients. Am J Med. 1979 May;66(5):811-6. doi: 10.1016/0002-9343(79)91121-5. PMID: 155988. Reference #2: Smith CA, McCracken C, Thomas AS, et al. Long-term Outcomes of Tetralogy of Fallot: A Study From the Pediatric Cardiac Care Consortium. JAMA Cardiol. 2019;4(1):34–41. doi:10.1001/jamacardio.2018.4255 Reference #3: Bertranou EG, Blackstone EH, Hazelrig JB, Turner ME, Kirklin JW. Life expectancy without surgery in tetralogy of Fallot. Am J Cardiol. 1978 Sep;42(3):458-66. doi: 10.1016/0002-9149(78)90941-4. PMID: 685856. DISCLOSURES: No relevant relationships by Erica Altschul No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Jonathan Moore

SESSION TITLE: Autoimmune Diffuse Lung Disease Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Interstitial lung disease (ILD) associated with connective tissue diseases (CTD) present with varying degrees of severity and functional impairment. Patients with CTD-ILD may often initially present for pulmonary evaluation. Pulmonologists must be familiar with the spectrum of CTD syndromes, the associated serologic testing, and referral criteria to rheumatology.CASE PRESENTATION: A 62-year-old never-smoking female with prior mild COVID-19 infection, previously vaccinated, presented to clinic with a diagnosis of pulmonary fibrosis. She endorsed three years of progressive shortness of breath and dyspnea on exertion walking only eight blocks and with light household chores. The patient had worked as a professional chef in poorly ventilated kitchens. Review of systems was notable for morning stiffness and pain in bilateral hand joints with associated difficulty opening medication bottles secondary to symptoms. Previous computed tomography (CT) of the chest demonstrated peripheral, subpleural, and basal predominant reticulations accompanied by bronchiectasis and bronchioloectasis consistent with probable usual interstitial pneumonia (UIP). Envisia® genomic testing was performed and results were negative for idiopathic pulmonary fibrosis. Extensive serologic testing for CTD was performed, including rheumatoid factor and anti-cyclic citrullinated peptides which were normal. The patient was referred to rheumatology, and hand x-rays demonstrated diffuse MCP joint narrowing. The patient was diagnosed with seronegative rheumatoid arthritis (RA) with RA-ILD and started on treatment.DISCUSSION: Multiple society guidelines recommend serologic testing to rule out CTD-ILD in patients with new ILD. ILD has been reported to occur in 20-60% of patients with RA with multiple patterns. Patients with seronegative RA are more likely to develop extraarticular manifestations of RA including fibrotic lung disease. Patients who are asymptomatic from RA-ILD may be monitored clinically for worsening RA-ILD. The selection of patients for treatment with an immunosuppressive agent or glucocorticoids should be done with a multidisciplinary team. Patients with RA-ILD and a UIP pattern may not respond to immunosuppressive medications but are typically trialed on treatment for worsening lung disease. Randomized controlled trials that included patients with RA-ILD with fibrosis have suggested a role for nintedanib, an anti-fibrotic agent, in slowing the progression of forced vital capacity decline.CONCLUSIONS: CTD-ILD is a common diagnosis in pulmonary clinics, and ILD symptoms may be the chief complaint at presentation. Providers must be familiar with diagnostic criteria for CTD and obtain a detailed review of systems that might suggest the diagnosis of CTD. Early diagnosis of CTD-ILD and monitoring of disease activity is important to prevent progression of CTD-ILD.Reference #1: Yoo H, Hino T, Han J, et al. Connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial lung abnormality (ILA): Evolving concept of CT findings, pathology and management. Eur J Radiol Open. 2020;8:100311. Published 2020 Dec 16. doi:10.1016/j.ejro.2020.100311Reference #2: Sahatciu-Meka V, Rexhepi S, Manxhuka-Kerliu S, Rexhepi M. Extra-articular manifestations of seronegative and seropositive rheumatoid arthritis. Bosn J Basic Med Sci. 2010;10(1):26-31. doi:10.17305/bjbms.2010.2729Reference #3: Cottin V. Pragmatic prognostic approach of rheumatoid arthritis-associated interstitial lung disease. Eur Respir J. 2010 Jun;35(6):1206-8. doi: 10.1183/09031936.00008610. PMID: 20513909.DISCLOSURES: No relevant relationships by Brenda GarciaNo relevant relationships by Zein KattihNo relevant relationships by Priyanka MakkarNo relevant relationships by Jonathan Moore SESSION TITLE: Autoimmune Diffuse Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Interstitial lung disease (ILD) associated with connective tissue diseases (CTD) present with varying degrees of severity and functional impairment. Patients with CTD-ILD may often initially present for pulmonary evaluation. Pulmonologists must be familiar with the spectrum of CTD syndromes, the associated serologic testing, and referral criteria to rheumatology. CASE PRESENTATION: A 62-year-old never-smoking female with prior mild COVID-19 infection, previously vaccinated, presented to clinic with a diagnosis of pulmonary fibrosis. She endorsed three years of progressive shortness of breath and dyspnea on exertion walking only eight blocks and with light household chores. The patient had worked as a professional chef in poorly ventilated kitchens. Review of systems was notable for morning stiffness and pain in bilateral hand joints with associated difficulty opening medication bottles secondary to symptoms. Previous computed tomography (CT) of the chest demonstrated peripheral, subpleural, and basal predominant reticulations accompanied by bronchiectasis and bronchioloectasis consistent with probable usual interstitial pneumonia (UIP). Envisia® genomic testing was performed and results were negative for idiopathic pulmonary fibrosis. Extensive serologic testing for CTD was performed, including rheumatoid factor and anti-cyclic citrullinated peptides which were normal. The patient was referred to rheumatology, and hand x-rays demonstrated diffuse MCP joint narrowing. The patient was diagnosed with seronegative rheumatoid arthritis (RA) with RA-ILD and started on treatment. DISCUSSION: Multiple society guidelines recommend serologic testing to rule out CTD-ILD in patients with new ILD. ILD has been reported to occur in 20-60% of patients with RA with multiple patterns. Patients with seronegative RA are more likely to develop extraarticular manifestations of RA including fibrotic lung disease. Patients who are asymptomatic from RA-ILD may be monitored clinically for worsening RA-ILD. The selection of patients for treatment with an immunosuppressive agent or glucocorticoids should be done with a multidisciplinary team. Patients with RA-ILD and a UIP pattern may not respond to immunosuppressive medications but are typically trialed on treatment for worsening lung disease. Randomized controlled trials that included patients with RA-ILD with fibrosis have suggested a role for nintedanib, an anti-fibrotic agent, in slowing the progression of forced vital capacity decline. CONCLUSIONS: CTD-ILD is a common diagnosis in pulmonary clinics, and ILD symptoms may be the chief complaint at presentation. Providers must be familiar with diagnostic criteria for CTD and obtain a detailed review of systems that might suggest the diagnosis of CTD. Early diagnosis of CTD-ILD and monitoring of disease activity is important to prevent progression of CTD-ILD. Reference #1: Yoo H, Hino T, Han J, et al. Connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial lung abnormality (ILA): Evolving concept of CT findings, pathology and management. Eur J Radiol Open. 2020;8:100311. Published 2020 Dec 16. doi:10.1016/j.ejro.2020.100311 Reference #2: Sahatciu-Meka V, Rexhepi S, Manxhuka-Kerliu S, Rexhepi M. Extra-articular manifestations of seronegative and seropositive rheumatoid arthritis. Bosn J Basic Med Sci. 2010;10(1):26-31. doi:10.17305/bjbms.2010.2729 Reference #3: Cottin V. Pragmatic prognostic approach of rheumatoid arthritis-associated interstitial lung disease. Eur Respir J. 2010 Jun;35(6):1206-8. doi: 10.1183/09031936.00008610. PMID: 20513909. DISCLOSURES: No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Priyanka Makkar No relevant relationships by Jonathan Moore

SESSION TITLE: Treating the Heart in the ICU Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Orotracheal intubation is performed across a wide variety of clinical settings. Injuries sustained during intubation are more frequent in emergent, high-risk intubations. Rates of injury are inversely correlated with the provider's technical skill. High risk and emergent intubations should be performed by the most experienced member of the treatment team.CASE PRESENTATION: A 56-year-old woman with history of chronic obstructive pulmonary disease was found to be comatose and cyanotic in her bathtub by emergency medical services. She was urgently intubated with improvement in color. The patient regained consciousness during transport, subsequently self-extubated and was transferred to the emergency department. She reported recreational use of fentanyl prior to this episode. On presentation, her oxygen saturation was normal while breathing ambient air. She then suddenly developed hemoptysis, approximately 20 milliliters total, accompanied by progressively increasing oxygen requirements of up to 6 liters per minute by nasal cannula. Chest radiography revealed emphysema of the neck and pneumomediastinum. Computed tomography of the chest demonstrated laceration to the posterior tracheal membrane measuring 4 centimeters in length by 0.5 centimeters in depth, accompanied by prevertebral emphysema extending from the level of C1 to T2. Thoracic surgery was consulted, and the patient was taken emergently for awake inspection bronchoscopy. She underwent primary repair of the defect with an uncomplicated post-operative course and was discharged to an inpatient rehabilitation program.DISCUSSION: Injury during orotracheal intubation can occur at any point from the lip to trachea. Dental injury is the most frequently reported complication followed by direct soft tissue injury of the lip, buccal mucosa, tongue, vocal cords, larynx, and oropharynx. Tracheal rupture associated with intubation is an extremely rare occurrence with a reported incidence of 0.005%. The most common cause of injury to the pars membranosa is believed to be from the rapid movement of the endotracheal tube with an over-inflated cuff. Tracheal rupture tends to have a female predilection in the setting of weaker membranes and smaller tracheas, which increases risk of injury from over-distended cuffs. Large defects with extensive emphysema typically require primary repair. However, there are case reports of conservative management of small defects with good outcomes. It is difficult to confirm the cause of our patient's tracheal rupture, but her abrupt self-extubation is the most likely etiology, making this presentation exceptionally unusual.CONCLUSIONS: Providers performing orotracheal intubation should be familiar with both common and uncommon complications of intubation. Incidence of tracheal rupture from intubation is very low. Providers should be aware of the signs of perforation to allow for prompt diagnosis and treatment.Reference #1: Lim H, Kim JH, Kim D, et al. Tracheal rupture after endotracheal intubation - A report of three cases -. Korean J Anesthesiol. 2012;62(3):277-280. doi:10.4097/kjae.2012.62.3.277Reference #2: Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. 2009 Jun;35(6):1056-62. doi: 10.1016/j.ejcts.2009.01.053. Epub 2009 Apr 14. PMID: 19369087.Reference #3: Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette CH. Management of postintubation tracheobronchial ruptures. Chest. 2006 Aug;130(2):412-8. doi: 10.1378/chest.130.2.412. PMID: 16899839.DISCLOSURES: No relevant relationships by Brian BirnbaumNo relevant relationships by Brenda GarciaNo relevant relationships by Zein KattihNo relevant relationships by Stephen MachnickiNo relevant relationships by Bushra MinaNo relevant relationships by Jonathan Moore SESSION TITLE: Treating the Heart in the ICU Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Orotracheal intubation is performed across a wide variety of clinical settings. Injuries sustained during intubation are more frequent in emergent, high-risk intubations. Rates of injury are inversely correlated with the provider's technical skill. High risk and emergent intubations should be performed by the most experienced member of the treatment team. CASE PRESENTATION: A 56-year-old woman with history of chronic obstructive pulmonary disease was found to be comatose and cyanotic in her bathtub by emergency medical services. She was urgently intubated with improvement in color. The patient regained consciousness during transport, subsequently self-extubated and was transferred to the emergency department. She reported recreational use of fentanyl prior to this episode. On presentation, her oxygen saturation was normal while breathing ambient air. She then suddenly developed hemoptysis, approximately 20 milliliters total, accompanied by progressively increasing oxygen requirements of up to 6 liters per minute by nasal cannula. Chest radiography revealed emphysema of the neck and pneumomediastinum. Computed tomography of the chest demonstrated laceration to the posterior tracheal membrane measuring 4 centimeters in length by 0.5 centimeters in depth, accompanied by prevertebral emphysema extending from the level of C1 to T2. Thoracic surgery was consulted, and the patient was taken emergently for awake inspection bronchoscopy. She underwent primary repair of the defect with an uncomplicated post-operative course and was discharged to an inpatient rehabilitation program. DISCUSSION: Injury during orotracheal intubation can occur at any point from the lip to trachea. Dental injury is the most frequently reported complication followed by direct soft tissue injury of the lip, buccal mucosa, tongue, vocal cords, larynx, and oropharynx. Tracheal rupture associated with intubation is an extremely rare occurrence with a reported incidence of 0.005%. The most common cause of injury to the pars membranosa is believed to be from the rapid movement of the endotracheal tube with an over-inflated cuff. Tracheal rupture tends to have a female predilection in the setting of weaker membranes and smaller tracheas, which increases risk of injury from over-distended cuffs. Large defects with extensive emphysema typically require primary repair. However, there are case reports of conservative management of small defects with good outcomes. It is difficult to confirm the cause of our patient's tracheal rupture, but her abrupt self-extubation is the most likely etiology, making this presentation exceptionally unusual. CONCLUSIONS: Providers performing orotracheal intubation should be familiar with both common and uncommon complications of intubation. Incidence of tracheal rupture from intubation is very low. Providers should be aware of the signs of perforation to allow for prompt diagnosis and treatment. Reference #1: Lim H, Kim JH, Kim D, et al. Tracheal rupture after endotracheal intubation - A report of three cases -. Korean J Anesthesiol. 2012;62(3):277-280. doi:10.4097/kjae.2012.62.3.277 Reference #2: Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. 2009 Jun;35(6):1056-62. doi: 10.1016/j.ejcts.2009.01.053. Epub 2009 Apr 14. PMID: 19369087. Reference #3: Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette CH. Management of postintubation tracheobronchial ruptures. Chest. 2006 Aug;130(2):412-8. doi: 10.1378/chest.130.2.412. PMID: 16899839. DISCLOSURES: No relevant relationships by Brian Birnbaum No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Stephen Machnicki No relevant relationships by Bushra Mina No relevant relationships by Jonathan Moore