CASE PRESENTATION:A 64-year-old man, originally from Puerto Rico, was referred for suspected interstitial lung disease based on incidental chest imaging findings. He had no respiratory concerns such as cough or dyspnea. He had preserved exercise tolerance and walked multiple city blocks without stopping.

Background Gastric point of care ultrasound (POCUS) has been used by clinicians to evaluate gastric contents prior to the induction for intubation in the intensive care unit. This is of particular importance as the presence of gastric contents increases the risk of aspiration during induction, which itself carries increased morbidity and mortality. In upper gastrointestinal bleeds (GIB), sonographic assessment prior to evaluation with esophagogastroduodenoscopy (EGD) may be of significant utility both in risk stratification of anesthesia and the clinical concern for ongoing bleeding. Research question: Can gastric POCUS be used to reliably measure gastric contents as compared to the gold standard of EGD in upper GIB? Study design and methods: The primary goal of the study was to compare Esophagogastroduodenoscopy (EGD) stomach content measurement, the gold standard in the diagnosis and potential management of gastrointestinal bleeding, with bedside ultrasound measurement in patients undergoing EGD in all settings. We report the sensitivity, specificity, positive predictive value [PPV] and the negative predictive value [NPV] with their exact 95% confidence intervals (CI). We summarized descriptively the distribution of POCUS measurements, in the cases where the assessment of gastrointestinal content differed between the two methods [specifically detection of contents with ultrasound ie US > 0, but absence of contents on EGD ie EGD=0]. SAS 9.4 (SAS Institute, Inc., Cary, NC) was used for the data analysis. Results When comparing POCUS measurements to EGD to detect the presence or absence of stomach contents, the sensitivity of the US measurement was 75.0% (95% CI:19.4-99.4), while the specificity was 76.1% (95% CI:61.2-87.4). The negative predictive value (NPV) was 97.2% (95% CI: 85.5-99.9). The positive predictive value (PPV) was 21.4% (95% CI: 4.7%- 50.1%), based on the 14 observations with US > 0. The Median (IQR) of POCUS for these 11 observations were 97.8 (18.7-260.8). Interpretation: Gastric ultrasound may be used for gastric content assessment prior to EGD in cases of suspected GIB. Gastric POCUS has a high negative predictive value to exclude the presence of stomach contents. This may have relevance in critical care settings where a high aspiration risk due to suspected stomach contents may lead to need for airway protection via advanced airway and general anesthesia.

Background Bedside percutaneous dilatational tracheostomy is a commonly performed procedure in the Intensive Care Unit with a steep learning curve. Checklists and standardized protocols have been established as essential tools for mitigating medical error and enhancing patient safety during critical care procedures. Research Question To assess the feasibility and safety profile of a percutaneous tracheostomy protocol, performed by pulmonary and critical care fellows, which integrates a multi-component checklist, tracheal ultrasound and a unique dual-visualization technique for endotracheal tube management. Study Design and Methods We conducted a retrospective review of all patients (n = 49) who underwent bedside percutaneous tracheostomy using a standardized protocol between November 1, 2022, and October 31, 2024. Key components of the protocol included rigorous pre-procedure assessment with standard tracheal ultrasound stations, a mandatory checklist, and endotracheal tube retraction under dual video laryngoscopy and bronchoscopy. Outcomes analyzed included major bleeding, site infection, and airway complications. Results A total of 49 percutaneous tracheostomy procedures were successfully performed over the 24-month period. No major bleeding episodes or pressure ulcers were identified. There was a single complication involving loss of airway due to endotracheal tube balloon rupture. Critically, the patient was rapidly re-intubated without any hypoxemia or hemodynamic instability, which may be attributed to the immediate availability and use of the dual-visualization safeguard. Interpretation The implementation of this protocolized, checklist-driven approach to bedside percutaneous tracheostomy is feasible and safe within the framework of a pulmonary and critical care fellowship training model. The use of a novel dual-visualization technique (video laryngoscopy and bronchoscopy) during endotracheal tube retraction serves as a robust fail-safe, which may enhance patient safety during airway-compromised events.

INTRODUCTION:Pulmonary embolism is the third most common cause of cardiovascular death in the US with a high financial burden. Data on cost-analysis is limited in comparing advanced treatment modalities. METHODS:A cohort of patients were selected from a PERT registry database from cases at a tertiary center in a metropolitan area between 2016 and 2023. Patients were treated with either anticoagulation alone, CDT, or MT. The primary outcome was revenue-per-case. RESULTS:MT had the highest revenue-per-case, with a median (IQR) of $59,058 ($42,827-$86,950) (p < 0.0001). CDT had a median (IQR) revenue-per-case of $19,007 ($14,062-$34,651). Anticoagulation alone had a median (IQR) revenue-per-case of $16,171 ($12,666-$31,473). Margin-per-case closely paralleled the primary outcome. While hospital length of stay, survival at discharge, and 90-day readmission were not different among the groups, ICU utilization was 20 % in anticoagulation patients, 100 % in CDT patients, and 24 % in MT patients (p < 0.0001). CTEPH was identified in 12 % of the anticoagulation group, 12 % of the CDT patients, and none of the MT patients (p = 0.04). DISCUSSION:MT has a significantly higher revenue-per-case compared with anticoagulation alone and CDT. ICU utilization of mechanical thrombectomy was lower than catheter-directed thrombolysis and near the ICU utilization with anticoagulation alone. Institution policies and device choice may impact these outcomes, which may vary by center. CONCLUSIONS:Advanced therapies that can prevent the downstream sequalae of PE have higher cost but may be more advantageous, and further research is required to evaluate long term benefits.

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.

SESSION TITLE: Challenging Cases in Sleep Medicine SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Pediatric Autoimmune Neuropsychiatric Disorders associated with streptococcal infections (PANDAS) is a known rare molecular mimicry disease. (1) First discovered in 1998 when patients with preceding group A streptococcus (GAS) infections developed abrupt onset obsessive compulsive (OCD) and tic disorders. This occurs by cross linking of antibodies to the basal ganglia inducing autoimmune response and neurological abnormalities. (2) These subsets of patients can also develop narcolepsy through a similar process. This mimicry leads to destruction of the orexin neurons and development of narcolepsy. (3,4) This is very rare and can easily be mistaken for other sleep related disorders. This is a case of a patient who developed narcolepsy symptoms at 15 and was never officially diagnosed until age 32. CASE PRESENTATION: 32-year-old female presenting to sleep clinic complaining of hypersomnolence. Symptoms improved with her 5 weeks of antibiotics. A few years later she began to fall asleep at inappropriate times with hallucinations, but this was attributed to her uncontrolled OCD. She was treated for her OCD and hypersomnolence with Wellbutrin, methylphenidate, and Zoloft. She would go to began at the age of 15 when she developed pneumonia and developed sudden onset OCD that sleep at 2AM and awaken at 9AM with weekends sleeping until 3PM and feeling refreshed. She would nap 1-4 hours during the day also feeling partly refreshed. In 2009 She undergoes PSG with MSLT with sleep onset of 30 minutes, high stage III sleep of 47.4%, REM latency of 78.5 minutes. MSLT with 4 naps, sleep onset of 2.6 minutes, and 4 SOREMs. She then returns to college with no follow up and was told of possible narcolepsy. A few years later she returns to second sleep clinic with worsening of symptoms. Concern was that her SSRI therapy was interfering with the validity of the initial MSLT. Stimulants and SSRI were held for 7 days and tests repeated MSLT with 4 naps and sleep latency of 7.5 minutes with no episodes of REM sleep. Now diagnosed with idiopathic hypersomnolence with delayed sleep phase. During the next few years her PANDAS worsens, and she would return to sleep clinic a few years later with testing repeated. MSLT and PSG showed sleep latency of 4.8 minutes and REM latency of 2.1. Now formally diagnosed with narcolepsy DISCUSSION: PANDAS is a molecular mimicry disease that leads to destruction in the basal ganglia and development of severe OCD and tic disorder. (2) Similar hypothesis exists for the development of narcolepsy. This is called the two hit hypothesis, where the first hit is the strep infection leading to the priming of the immune system. Then a second hit leads the immune system to cross the blood brain barrier and destruction of oxecretin cells leading to narcolepsy symptoms. (3,4) CONCLUSIONS: PANDAS molecular mimicry can lead to similar process in the brain inducing narcolepsy. These patients can be on multiple medications that make testing and diagnosis challenging. This case highlights the complexity and how the treatment of the PANDAS can also help the sleep disorder. REFERENCE #1: 1. Giovannoni G. PANDAS: overview of the hypothesis. Adv Neurol 2006;99: 159–165. REFERENCE #2: Macerollo A, Martino D. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept. Tremor Other Hyperkinet Mov (N Y). 2013 Sep 25;3:tre-03-167-4158-7. doi: 10.7916/D8ZC81M1. PMID: 24106651; PMCID: PMC3783973. REFERENCE #3: 3. Buonocore SM, van der Most RG. Narcolepsy and H1N1 influenza immunology a decade later: What have we learned? Front Immunol. 2022 Oct 12;13:902840. doi: 10.3389/fimmu.2022.902840. PMID: 36311717; PMCID: PMC9601309.4. Giannoccaro MP, Pizza F, Jacobson L, et al Neuronal surface antibodies are common in children with narcolepsy and active movement disorders Journal of Neurology, Neurosurgery & Psychiatry 2021;92:111-112. DISCLOSURES: No relevant relationships by Matthew Ballenberger No relevant relationships by Simon Meredith No relevant relationships by Margarita Oks

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.

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Hemoglobin (Hb) sickle cell (HbSC) disease is a common variant of sickle cell disease (SCD). HbSC is thought to be a more mild variant of SCD with less severe complications and a longer projected life span. Acute pulmonary hypertension with decompensated right heart failure is a known rare, life threatening complication of acute chest syndrome (ACS) in SCD that has rarely been reported in HbSC disease. This condition can be difficult to manage and easily missed resulting in significant patient morbidity and mortality. CASE PRESENTATION: A 62 year-old man with a history of HbSC disease presented with diffuse limb pain that did not resolve with Ibuprofen. He was afebrile, saturating 100% on room air, hemoglobin was 10.6 g/dL and had no opacities on a chest X-ray (figure 1a.). He was started on intravenous fluids and opioids and developed a fever with increasing oxygen requirements and new opacities on a chest x-ray (figure 1b.) consistent with ACS. Point-of-care ultrasound showed a severely dilated right ventricle (RV) with reduced systolic function and bowing of the septum into the left ventricular (LV) cavity during diastole and systole suggestive of RV volume and pressure overload. Findings were confirmed with an echocardiogram revealing a normal LV ejection fraction and an RV systolic pressure (RVSP) of 48 mmHg. A comparative echocardiogram from 5 months prior showed no abnormalities. EKG changes showed nonspecific ST segment changes. A CT-chest was negative for acute pulmonary embolism. Hgb electrophoresis showed 49.2% HbS and 44.2% Hbc, and he underwent an exchange transfusion with 6 units of packed red blood cells. He developed cardiogenic shock requiring pressors and inotropes and was aggressively diuresed with improvement in hemodynamics. His mental status did not recover with cessation of sedation and a CT-head revealed diffuse acute strokes. His family elected for cessation of care and he subsequently expired. DISCUSSION: Acute pulmonary hypertension with decompensated right heart failure is extremely rare in patients with HbSC disease. The pathophysiology is related to micro-occlusion of the pulmonary vasculature due to sickling of erythrocytes. Management of this disease is extremely challenging as patients with vasooclusive crises are treated with aggressive fluid administration to prevent sickling and progression of disease which exacerbate right heart failure and leads to RV dilation causing interventricular dependence, obliteration of the LV cavity and cardiogenic shock. Treatment must target resolution of sickling with exchange transfusion with aggressive diuresis to offload the RV and improve hemodynamics. CONCLUSIONS: HbSC is thought to be a more mild variant of SCD, but our case demonstrates that patients with HbSC disease can develop severe complications from acute chest syndrome including decompensated right failure from acute pulmonary hypertension. This disease can be easily missed if not looked for as symptoms can mimic worsening of acute chest syndrome and progression to multiorgan failure syndrome. We recommend that all patients with HbSC who experience worsening acute chest syndrome should undergo screening ultrasonography to detect signs of right heart failure prompting early treatment to prevent disease progression that could result in significant morbidity and mortality. REFERENCE #1: Pecker LH, Schaefer BA, Luchtman-Jones L. Knowledge insufficient: the management of haemoglobin SC disease. Br J Haematol. 2017 Feb;176(4):515-526. doi: 10.1111/bjh.14444. Epub 2016 Dec 16 REFERENCE #2: Mekontso Dessap A, Leon R, Habibi A, Nzouakou R, Roudot-Thoraval F, Adnot S, Godeau B, Galacteros F, Brun-Buisson C, Brochard L, Maitre B. Pulmonary hypertension and cor pulmonale during severe acute chest syndrome in sickle cell disease. Am J Respir Crit Care Med. 2008 Mar 15;177(6):646-53. doi: 10.1164/rccm.200710-1606OC REFERENCE #3: Lionnet F, Hammoudi N, Stojanovic KS, Avellino V, Grateau G, Girot R, Haymann JP. Hemoglobin sickle cell disease complications: a clinical study of 179 cases. Haematologica. 2012 Aug;97(8):1136-41. doi: 10.3324/haematol.2011.055202. Epub 2012 Feb 7. PMID: 22315500 DISCLOSURES: No relevant relationships by Matthew Ballenberger No relevant relationships by Simon Meredith

Background: Percutaneous tracheostomy placement is a common procedure performed in the intensive care unit. The use of an anterior neck ultrasound exam is routinely performed preprocedure, allowing for vessel visualization in determining the safety and feasibility of performing the procedure bedside. This prospective observational cohort study was conducted to determine whether vasculature in the anterior neck, seen on bedside ultrasound exam, contributes to bleeding complications during or after percutaneous tracheostomy (PCT) placement. Research Question: Do the vessels identified on preprocedure neck ultrasound affect the risk of bleeding during and after bedside PCT placement? Study Design and Methods: Preprocedural ultrasound was used to identify standard anatomical landmarks and vascular structures in the anterior neck in all patients undergoing bedside PCT placement under bronchoscopic guidance. A blinded survey of our recorded preprocedural images was provided to an expert panel who regularly perform bedside PCTs to determine the influence the images have on their decision to perform the procedure at the bedside. Results: One out of 15 patients (7%) had intra-operative minimal bleeding which was not clinically significant and resolved by gauze compression for 30 s. None of the patients had post-procedural bleeding after tracheostomy placement. Based on the blinded interpretation of neck ultrasound, there was 0.214 inter-operator variability among the expert panelists for decision-making regarding performing bedside PCT. Interpretation: Vessels visualized with anterior neck ultrasound were found to be small venous structures and did not significantly contribute to bleeding risk in patients who underwent PCT placement. The size and location of veins on neck ultrasound may commonly contribute to abandoning bedside PCT. This study suggests that veins measuring 3.9 mm or smaller identified at the site of access do not increase the risk of bleeding in PCT placement.

INTRODUCTION: Calcific uremic arteriolopathy (CUA), or calciphylaxis, is a rare condition most often seen in end-stage renal disease (ESRD) patients and characterized by cutaneous arteriolar calcification leading to tissue ischemia, vessel necrosis and nonhealing skin lesions1.We present a case of undifferentiated shock in a patient with ESRD secondary to polycystic kidney disease (PCKD). CASE PRESENTATION:A 65-year-old female with a past medical history of ESRD secondary to PCKD on hemodialysis (HD) via an arteriovenous (AV) fistula, hypertension, heart failure with reduced ejection fraction, nonobstructive coronary artery disease, peripheral arterial disease, and history of pulmonary embolism presented with progressive weakness and generalized malaise for one week leading to missed dialysis.Initial labs demonstrated hyperkalemia (Figure 1).Physical exam was notable for severe breast pain and an immobile subcutaneous right breast mass with overlying induration and peau d'orange appearance.The patient was persistently hypotensive with systolic blood pressures ranging from the 60s to 80s and with evidence of hypoperfusion requiring phenylephrine use in the setting of new left ventricular outflow tract obstruction.Workup for persistent hypotension included additional labwork (Figure 2), which demonstrated evidence of secondary hyperparathyroidism.The patient was started on cinacalcet.Further imaging including computed tomography (CT) imaging of the chest, abdomen, and pelvis, ultrasound of the AV fistula, a gallium scan, and a positron emission tomography (PET) scan.The patient was found to have a localized fluid collection adjacent to the right AV fistula which was drained, and she was started on broad-spectrum antibiotics without resolution of shock.A biopsy of the right breast revealed epidermal and dermal necrosis with fibrinoid occlusion and necrosis of blood vessels, focal necrotizing suppurative inflammation involving the fibroadipose tissue and blood vessels in the subcutis, consistent with calciphylaxis.The patient was started and uptitrated on midodrine followed by fludrocortisone for persistent hypotension in the setting of ESRD with ultimate improvement in her blood pressure.DISCUSSION: This patient's undifferentiated shock led to the accumulation of findings that are known risk factors for and sequelae of CUA.The patient's hyperparathyroidism was likely longstanding given the degree of artery calcification, osteolytic lesions of the axial skeleton and pathologic fractures.Although an initial hypercoagulability workup was negative, many local prothrombotic factors play a role in the development of calciphylaxis2.Thus, her history of pulmonary embolism and deep vein thromboses found on ultrasound of the right upper extremity may correlate with CUA.Persistent hypotension has been described in the setting of CUA in one case report in the literature with a similar presentation to our patient3.Though skin manifestations and severe pain are classic findings, the disease can affect nearly any organ1. CONCLUSIONS:Because CUA typically presents with severe pain and classic skin lesions, atypical presentations require a high index of suspicion.One-year mortality rates range between 45% and 80%1.Persistent hypotension and severe breast pain without typical skin changes can be a rare presentation of CUA.