Acute Hypoxic Respiratory Failure Research Articles

Intraperitoneal oxygen microbubble therapy: A novel approach to enhance systemic oxygenation in a smoke inhalation model of acute hypoxic respiratory failure

BackgroundPatients suffering from severe acute respiratory distress syndrome (ARDS) face limited therapeutic options and alarmingly high mortality rates. Refractory hypoxemia, a hallmark of ARDS, often necessitates invasive and high-risk treatments. Oxygen microbubbles (OMB) present a promising approach for extrapulmonary oxygenation, potentially augmenting systemic oxygen levels without exposing patients to significant risks. MethodsRats with severe, acute hypoxemia secondary to wood smoke inhalation (SI) received intraperitoneal (IP) bolus injections of escalating weight-by-volume (BW/V) OMB doses or normal saline to determine optimal dosage and treatment efficacy. Subsequently, a 10 % BW/V OMB bolus or saline was administered to a group of SI rats and a control group of healthy rats (SHAM). Imaging, vital signs, and laboratory studies were compared at baseline, post-smoke inhalation, and post-treatment. Histological examination and lung tissue wet/dry weight ratios were assessed at study conclusion. ResultsTreatment with various OMB doses in SI-induced acute hypoxemia revealed that a 10 % BW/V OMB dose significantly augmented systemic oxygen levels while minimizing dose volume. The second set of studies demonstrated a significant increase in partial pressure of arterial oxygen (PaO2) and normalization of heart rate with OMB treatment in the SI group compared to saline treatment or control group treatment. ConclusionsThis study highlights the successful augmentation of systemic oxygenation following OMB treatment in a small animal model of severe hypoxemia. OMB therapy emerges as a novel and promising treatment modality with immense translational potential for oxygenation support in acute care settings.

SAT481 Metastatic Choriocarcinoma, A Rare Cause of hCG-Mediated Hyperthyroidism

Abstract Disclosure: S. Jain: None. M. Crabtree: None. C. Houston: None. Background: Structural homology between human chorionic gonadotropin (hCG) and thyrotropin stimulating hormone (TSH) allows high levels of hCG to exert thyrotropic effects via TSH receptors. Although hCG-mediated hyperthyroidism is most frequently encountered in the context of pregnancy, it also occurs rarely as a paraneoplastic syndrome. We present a case of hCG-mediated hyperthyroidism due to metastatic choriocarcinoma in a postmenopausal woman. Case Presentation: A previously healthy 59-year-old woman was evaluated for shortness of breath and found to have multiple lung nodules concerning for metastatic malignancy. Further imaging demonstrated an enlarged heterogeneous uterus with an enlarged endometrial cavity. Endometrial biopsy revealed poorly differentiated carcinoma with some areas of possible squamous differentiation. Subspecialty cytopathology review was requested. One week after biopsy, the patient was brought to the emergency department with acute hypoxic respiratory failure following a seizure. She was found to be febrile, tachycardic, hypertensive, and minimally responsive. Head CT revealed a left frontal brain mass with surrounding vasogenic edema, concerning for metastasis. Laboratory evaluation revealed TSH of 0.03 mIU/L (normal 0.35-4.94) and free T4 of 2.30 ng/dL (normal 0.70-1.48). Thyroid stimulating immunoglobulin was negative. Beta-hCG was found to be significantly elevated at 982,093 mIU/mL after 1:100 dilution. She was started on treatment with propranolol, dexamethasone, and chemotherapy with etoposide and cisplatin. Meanwhile, cytopathology review identified scattered cells with features of choriocarcinoma and positive hCG immunostaining, felt to represent a diagnosis of poorly differentiated choriocarcinoma. After one cycle of chemotherapy, the patient’s beta-hCG decreased to 477,668 mIU/mL and free T4 decreased to 1.05 ng/dL. Due to progressive worsening of her clinical status, she was transitioned to palliative care and passed away on hospital day 14. Discussion: Hyperthyroidism mediated by hCG is most often seen in patients with hyperemesis gravidarum, gestational transient thyrotoxicosis, or gestational trophoblastic disease. Our case underscores the importance of considering hCG-mediated hyperthyroidism outside the context of pregnancy. Rare paraneoplastic sources of hCG include choriocarcinoma, seminoma, and other germ cell tumors. Hyperthyroidism in these cases is usually subclinical or mild, but instances of thyroid storm have been reported with metastatic disease. Beta blockers, glucocorticoids, and thionamides can be used as temporizing measures, but definitive therapy requires treatment of the causative malignancy. Presentation Date: Saturday, June 17, 2023

SAT196 COVID-19 Pneumonia And Primary Hyperparathyroidism Exacerbation

Abstract Disclosure: A. Khan: None. P. Rimal: None. M. Biggs: None. A. Ahmed: None. C. Musurakis: None. J.L. Gilden: None. A. Moid: None. Introduction: It is well known that COVID-19 virus damages the body by either inflicting the injury directly, or by initiating a systemic immune response, resulting in inflammation. Our case report explores how parathyroid glandular dysfunction and calcium levels (Ca) can be affected in a patient with active COVID-19 pneumonia. Clinical Case: A 58-year-old male, unvaccinated for COVID-19, with COPD, primary hyperparathyroidism (PHPT), chronic kidney disease, and ethanol use presented to the emergency room with confusion, vomiting, and lethargy. Preadmission medications included hydrochlorothiazide. Following a positive COVID-19 test, he was diagnosed with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. After emergent treatment with BiPAP and IV steroids, he was transferred to the ICU, where he completed treatment with remdesivir, dexamethasone, and baricitinib. He was also treated for ethanol withdrawal. Notably, this patient had a history of chronic asymptomatic hypercalcemia secondary to PHPT with Ca prior to admission ranging from 10.9-13.6 mg/dl (nl=8.5-10.1mg/dl), PTH range 145-345 pg/ml (nl=14-65 pg/ml), creatinine (Cr) 1.2-1.4 mg/dl (nl= 0.67-1.17 mg/dl). On this admission, Ca was 12.2mg/dl, albumin 2.4 g/dl (3.4-5.0 g/dl), PTH 531 pg/ml, Cr 3.4 mg/dl, 25OH vitamin D 29.3 ng/mL (nl= 30-100 ng/mL). After fluids, Ca initially improved to 10.9mg/dl and Cr soon after normalized. Mental status also improved after hydration. However, Ca then rose significantly to 14.1mg/dl with mental status decline. IV zoledronic acid was administered, resulting in lowering serum calcium and improvement of mental status. Conclusion: This patient’s clinical course was notable for the improvement of Ca initially with hydration. However, a significant rise in Ca approaching parathyroid crisis range was seen shortly thereafter, despite normalization of Cr. Whereas hypocalcemia has been noted in most cases of Ca dysfunction associated with COVID-19 infection, in this case, we postulate that the COVID-19 infection may have triggered parathyroiditis, thus exacerbating the underlying PHPT. One such mechanism is the use of receptors like angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) by COVID-19 virus, which are found on endocrine glands including the parathyroid. Similarly, COVID-19 virus exerts its inflammatory effects using IL-6, which is also a key cytokine that causes hypercalcemia by stimulating bone resorption. Furthermore, COVID-19 infection is notorious for causing nausea/vomiting, and diarrhea, culminating in dehydration which worsens hypercalcemia. It is therefore necessary that physicians foresee impending complications of COVID-19 infection with concurrent parathyroid disease and take early steps to prevent and treat them. Presentation: Saturday, June 17, 2023

S3647 A Unique Presentation of Autoimmune Hepatitis as Acute Hypoxic Respiratory Failure

S3647 A Unique Presentation of Autoimmune Hepatitis as Acute Hypoxic Respiratory Failure

Comparison of High Flow Nasal Cannula and Continuous Positive Airway Pressure in COVID-19 Patients With Acute Respiratory Distress Syndrome in Critical Care Unit: A Randomized Control Study.

Background and objective Acute hypoxic respiratory failure in coronavirus disease 2019 (COVID-19) pneumonia has been treated with oxygen delivered by oxygen masks and non-invasive ventilation (NIV) with continuous positive airway pressure (CPAP), and more recently with high-flow nasal cannula (HFNC) devices. There is a paucity of randomized controlled trials to compare the efficacy of CPAP with HFNC in COVID-19 pneumonia. We conceptualized a randomized control study to compare the efficacy of HFNC and CPAP in reducing the need for invasive mechanical ventilation, estimation of mechanical ventilation-free days, and risk of intubation in COVID-19 patients with hypoxic respiratory failure. Methodology One hundred consecutive patients who satisfied the inclusion criteria were included in the trial. The patients were then randomly allocated to receive either CPAP or HFNC with settings as per the study protocol. The patients were deemed to have achieved the study endpoint when they were intubated due to any reason or successfully weaned from NIV to conventional oxygen therapies. The number of patients who required invasive ventilation and the number of invasive ventilation-free days were recorded and analyzed. Results Nineteen (38%) patients in the CPAP group and 30 (60%) patients in the HFNC group required invasive mechanical ventilation and the difference was statistically significant (p = 0.03, 95%CI: 0.1829-0.9129). The median number of days free of invasive mechanical ventilation in the CPAP group (median=5 (interquartile range (IQR(=5,6)) was more than in the HFNC group (median=4 (IQR=3,4)) and this difference was statistically significant (p<0.000). The secondary analysis of risk evaluation for intubation done using the Cox regression model showed no significant factors that could have contributed to intubation in the study population. The Kaplan-Meyer curve was used to express the probability of a patient getting intubated and the calculated hazard ratio was 2.29. Conclusion The administration of CPAP significantly reduced the intubation rate and prolonged invasive mechanical ventilation-free period in COVID-19 patients with hypoxic respiratory failure. We also inferred a two-fold increase in the risk of intubation in patients receiving HFNC compared to CPAP.

Psittacosis caused severe community-acquired pneumonia accompanied by acute hypoxic respiratory failure: a multicenter retrospective cohort study from China

IntroductionPsittacosis can cause severe community-acquired pneumonia (CAP). The clinical manifestations of psittacosis range from subclinical to fulminant psittacosis with multi-organ failure. It is essential to summarize the clinical characteristic of patients with severe psittacosis accompanied by acute hypoxic respiratory failure (AHRF).MethodsThis retrospective study included patients with severe psittacosis caused CAP accompanied by AHRF from 19 tertiary hospitals of China. We recorded the clinical data, antimicrobial therapy, respiratory support, complications, and outcomes. Chlamydia psittaci was detected on the basis of metagenomic next-generation sequencing performed on bronchoalveolar lavage fluid samples. Patient outcomes were compared between the treatment methods.ResultsThis study included 45 patients with severe CAP and AHRF caused by psittacosis from April 2018 to May 2021. The highest incidence of these infections was between September and April. There was a history of poultry contact in 64.4% of the patients. The median PaO2/FiO2 of the patients was 119.8 (interquartile range, 73.2 to 183.6) mmHg. Four of 45 patients (8.9%) died in the ICU, and the median ICU duration was 12 days (interquartile range, 8 to 21) days. There were no significant differences between patients treated with fluoroquinolone initially and continued after the diagnosis, fluoroquinolone initially followed by tetracycline, and fluoroquinolone combined with tetracycline.ConclusionPsittacosis caused severe CAP seems not rare, especially in the patients with the history of exposure to poultry or birds. Empirical treatment that covers atypical pathogens may benefit such patients, which fluoroquinolones might be considered as an alternative.

The Modified Clinical Progression Scale for Pediatric Patients: Evaluation as a Severity Metric and Outcome Measure in Severe Acute Viral Respiratory Illness.

To develop, evaluate, and explore the use of a pediatric ordinal score as a potential clinical trial outcome metric in children hospitalized with acute hypoxic respiratory failure caused by viral respiratory infections. We modified the World Health Organization Clinical Progression Scale for pediatric patients (CPS-Ped) and assigned CPS-Ped at admission, days 2-4, 7, and 14. We identified predictors of clinical improvement (day 14 CPS-Ped ≤ 2 or a three-point decrease) using competing risks regression and compared clinical improvement to hospital length of stay (LOS) and ventilator-free days. We estimated sample sizes (80% power) to detect a 15% clinical improvement. North American pediatric hospitals. Three cohorts of pediatric patients with acute hypoxic respiratory failure receiving intensive care: two influenza (pediatric intensive care influenza [PICFLU], n = 263, 31 sites; PICFLU vaccine effectiveness [PICFLU-VE], n = 143, 17 sites) and one COVID-19 ( n = 237, 47 sites). None. Invasive mechanical ventilation rates were 71.4%, 32.9%, and 37.1% for PICFLU, PICFLU-VE, and COVID-19 with less than 5% mortality for all three cohorts. Maximum CPS-Ped (0 = home at respiratory baseline to 8 = death) was positively associated with hospital LOS ( p < 0.001, all cohorts). Across the three cohorts, many patients' CPS-Ped worsened after admission (39%, 18%, and 49%), with some patients progressing to invasive mechanical ventilation or death (19%, 11%, and 17%). Despite this, greater than 76% of patients across cohorts clinically improved by day 14. Estimated sample sizes per group using CPS-Ped to detect a percentage increase in clinical improvement were feasible (influenza 15%, n = 142; 10%, n = 225; COVID-19, 15% n = 208) compared with mortality ( n > 21,000, all), and ventilator-free days (influenza 15%, n = 167). The CPS-Ped can be used to describe the time course of illness and threshold for clinical improvement in hospitalized children and adolescents with acute respiratory failure from viral infections. This outcome measure could feasibly be used in clinical trials to evaluate in-hospital recovery.

Outcomes of Percutaneous Atrial Septal Defect Closure With Mitral Transcatheter Edge-to-Edge Repair and Transseptal Mitral Valve Replacement (2015 to 2020)

Patients who underwent transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) have a transeptal access created by an iatrogenic atrial septal defect (ASD) which leads to significant complications requiring closure. Given limited data, we used the National Inpatient Sample between 2015 and 2020 to evaluate the clinical outcomes of percutaneous closure of ASD (PC-ASD) in TEER/TMVR hospitalizations. A total of 44,065 eligible weighted hospitalizations with either TEER (n=39,625, 89.9%) or TMVR (n=4,440, 10.1%) with a higher rate of PC-ASD in the TMVR group (10.7% vs 2.0%, p<0.01). The TEER with PC-ASD group were more likely to experience acute heart failure and right ventricular failure and had longer hospital stays but there was no difference in in-hospital mortality compared with the no PC-ASD group. In the TMVR group, there was no difference in the odds of acute heart failure, right ventricular failure, cardiogenic shock, or acute hypoxic respiratory failure, but the odds of mechanical circulatory support, in-hospital mortality, and length of stay were significantly higher in patients with PC-ASD in the TMVR group. In conclusion, rates of percutaneous closure of ASD after TEER were lower than after TMVR and associated with worse in-hospital mortality in TMVR but not in TEER. Further prospective clinical trials are needed to identify patients who would benefit from the closure of iatrogenic ASD.

Effect of modified high-flow oxygen therapy on positive end-expiratory pressure and end-expiratory lung volume based on simulated lung platform

ObjectiveThe aim of this study was to assess the effect of modified high-flow oxygen therapy on end-expiratory lung volume (EELV) and positive end-expiratory pressure (PEEP) in tracheotomized patients with normal pulmonary, acute hypoxic respiratory failure (AHRF) or chronic obstructive pulmonary disease (COPD). MethodsA ventilator and an artificial lung model were used to simulate the normal or strong inspiratory effort state of normal lung, AHRF and COPD patients. The traditional high-flow respiratory humidification therapy device connected with a standard interface (group A), and the modified therapy device added two types of resistance valves (group B, inner diameter 7.7 mm, length 24.0 mm; group C, inner diameter 7.7 mm, length 34.0 mm) to the exhalation end of the standard interface. The changes of end-expiratory lung volume (ΔEELV) and PEEP with the increase of flow rate (10 L/min, 20 L/min, 30 L/min, 40 L/min, 50 L/min, 60 L/min) in the three groups was recorded. ResultsUnder simulated conditions of normal lung, AHRF and COPD, as the flow rate increased by using the modified therapy device, the PEEP values in all groups showed an exponential increasing trend, and the ΔEELV also increased accordingly. In addition, under the same flow rate level, the PEEP values of the two modified high-flow oxygen therapies (Group B and Group C) were significantly higher than those of the standard high-flow oxygen therapy (Group A) (p < 0.05). In the normal lung model with normal or strong inspiratory effort, and in the AHRF or COPD model with strong inspiratory effort, when the flow rate was higher than 30 L/min, the PEEP levels of Group B were significantly lower than those of Group C (p < 0.05). In the AHRF model with normal inspiratory effort, when the flow rate was between 10 L/min and 60 L/min, the PEEP levels of Group B were significantly lower than those of Group C (p < 0.05). Moreover, in the COPD model with normal inspiratory effort, the PEEP levels of Group B were significantly lower than that of Group C only when the flow rate was 60 L/min (p < 0.05). ConclusionThe addition of different types of resistance valves to the high-flow exhalation end may be a feasible solution to improve the clinical efficacy of tracheotomized high-flow oxygen therapy.

Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes

The COVID-19 pandemic led to a broad implementation of proning to enhance oxygenation in both self-ventilating and mechanically ventilated critically ill patients with acute severe hypoxic respiratory failure. However, there is little data on the impact of the timing of the initiation of prone positioning in COVID-19 patients receiving mechanical ventilation. In this study, we analyzed our proning practices in mechanically ventilated COVID-19 patients. There were 931 total proning episodes in 144 patients, with a median duration of 16 h (IQR 15–17 h) per proning cycle. 563 proning cycles were initiated within 7 days of intubation (early), 235 within 7–14 days (intermediate), and 133 after 14 days (late). The mean change in oxygenation defined as the delta PaO2/FiO2 ratio (ΔPF) after the prone episode was 16.6 ± 34.4 mmHg (p &lt; 0.001). For early, intermediate, and late cycles, mean ΔPF ratios were 18.5 ± 36.7 mmHg, 13.2 ± 30.4 mmHg, and 14.8 ± 30.5 mmHg, with no significant difference in response between early, intermediate, and late proning (p = 0.2), respectively. Our findings indicate a favorable oxygenation response to proning episodes at all time points, even after &gt;14 days of intubation. However, the findings cannot be translated directly into a survival advantage, and more research is needed in this area.

Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials

BackgroundAwake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19.MethodsCandidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers.ResultsEight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results.ConclusionsAwake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning.Trial registrationCRD42023394113.

Pneumococcal Endocarditis, Rare but Not Forgotten

Pneumococcal endocarditis incidence has significantly decreased since the advent of antibiotics but remains a significant cause of mortality and morbidity in high-risk groups, such as those with heart disease, chronic lung and liver disease, smoking, diabetes mellitus, and immunosuppression. We present a unique case of pneumococcal endocarditis with no clinical stigmata of infective endocarditis that manifested with acute hypoxic respiratory failure and severe aortic regurgitation. A large vegetation on the aortic valve was noted during surgery, with negative blood cultures and aortic valve tissue cultures but positive Streptococcus pneumoniae urinary antigen and polymerase chain reaction (PCR) test on the aortic valve.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

Abstract 516: Protein Energy Undernutrition Is Associated With Increased Mortality In Patients Admitted For Abdominal Aortic Aneurysm Rupture.

Objectives: Abdominal Aortic Aneurysm rupture is a surgical emergency associated with increased morbidity and mortality. Our study sought to estimate the impact of protein energy undernutrition (PEU) on the clinical outcome of patients admitted for abdominal aortic aneurysm rupture. Methods: Using the 2019 National Inpatients Sample Database, NIS was searched for adults with abdominal aortic aneurysm rupture as a principal diagnosis with or without PEU as a secondary diagnosis using ICD- 10 codes. Outcomes were in-hospital mortality, acute kidney injury (AKI), cardiogenic shock, CVA, myocardial infarction (MI), cardiac tamponade, acute hypoxic respiratory failure, intraoperative and post-procedure complications, and acute mesenteric ischemia. Results: 3,880 patients were admitted for abdominal aortic aneurysm rupture. Of those, 13% had a history of protein energy undernutrition. Patients with PEU had an increase in in-hospital mortality (p=0.0064) which was statistically significant. There was an increased rate of acute kidney injury (p&lt;0.0001), acute mesenteric ischemia (p=0.0005), intraoperative and post-procedure complication (p&lt;0.0001), and acute hypoxic respiratory failure (0.0034). Patients with PEU also had an increased length of hospital stay (18 days, 95% CI 15 - 21days VS 6 days, 95% CI 6 - 7) and hospital charges ($437,070.8, 95% CI $373,662.5 - $500,479.1 VS $ 200,328.1 95% CI, $184,811.6 - $217,844.6). However, there was no difference in the rate of cardiogenic shock (p=0.0812), cardiac tamponade (p=0.5813), and myocardial infarction (p=0.3389) Conclusion: Per this study, Protein Energy Undernutrition is associated with increased mortality when compared to the general population admitted for abdominal aortic aneurysms. Early identification and prevention of PEU can reduce mortality associated with abdominal aortic aneurysm rupture.

Abstract 266: The Outcome Of Aortic Dissection In Patients With Protein Energy Undernutrition, A Nationwide Analysis.

Objective: Acute Aortic Dissection is a life-threatening emergency associated with increased morbidity and mortality. Data on the effect of protein energy undernutrition(PEU) on the clinical outcome of patients admitted for aortic dissection are limited. Methods: Using the 2019 National Inpatient Sample Database, NIS was searched for adult patients with aortic dissection as the principal diagnosis with or without PEU as a secondary diagnosis using ICD-10 codes. The primary outcome was Inpatient mortality with secondary outcomes being acute kidney injury, cardiogenic shock, CVA, myocardial infarction, cardiac tamponade, acute hypoxic respiratory failure, intraoperative and post-procedure complications, and acute mesenteric ischemia Results: 17290 patients were admitted for acute aortic dissection. Of those, 8% had a history of PEU. Patients with PEU were older when compared with patients without PEU (mean age, 66.1 95% CI, 64.5-67.8 vs 63.8, 95% CI, 63.2- 64.3). There was no statistically significant difference in in-hospital mortality (p=0.1852) and acute mesenteric ischemia (p=0.4808). However, Patients with PEU had increased rate of acute kidney injury (p&lt;0.0001), myocardial infarction(p=0.0171), cardiogenic shock (p&lt;0.0001), CVA (p&lt;0.0001), cardiac tamponade (p=0.0171), acute hypoxic respiratory failure (p&lt;0.0001) and intraoperative and post-procedure complications (p=0.001). Patients with PEU also had increased length of hospital stay (23 days, 95% CI 21-25 VS 8 days, 95% CI 8 -9) and total hospital charges ($ 646967.2, 95% CI $533697.8 - $771236 VS $234639.3, 95% CI $218237 - $251040.8) Conclusion: This study shows no significant difference in mortality between patients with PEU admitted for aortic dissection compared to the general population. However, there were increased AKI, myocardial infarction, length of hospital stay, and charges in a patient with a history of PEU

Abstract 517: Covid Infection Increases Mortality In Patients Admitted For Acute Aortic Dissection.

Objectives: Coronavirus Disease 2019(Covid 19) can cause mild-to-severe multiorgan disease. In this study, we sought to estimate the impact of covid infection on the clinical outcome of patients admitted for acute aortic dissection. Methods: Using the 2020 National Inpatient Sample Database, NIS was searched for adults with acute aortic dissection as a principal diagnosis with or without Covid Infection as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality with secondary outcomes being acute kidney injury (AKI), cardiogenic shock, stroke, myocardial infarction (MI), intraoperative and post-procedure complications, acute mesenteric ischemia, length of hospital stays, and charges. Results: Of 15,325 patients admitted for acute aortic dissection, 1% had Covid infection. Patients with Covid were younger (62, 95% CI 57 - 68 VS 63, 95% CI 63 - 64). Patients with Covid had increased in-hospital mortality(p=0.0203) which was statistically significant. There was an increased rate of AKI (p=0.0203) and acute hypoxic respiratory failure (p&lt;0.0001). Patients with Covid infection also had increased length of hospital stay (18 days, 95% CI 12 - 25 VS 9 days, 95% CI 9 - 10) and total hospital charges ($ 413,351.5, 95% CI $ 249863.9 - $576,683.9 VS $275060.3, 95% CI $251,129 - $298,991.5). There was no difference in cardiogenic shock(p=0.7717), stroke (p=0.0787), cardiac tamponade (p= 0.7412), myocardial infarction (p=0.2487), intraoperative and post-procedure complications (p=0.8533) and acute mesenteric ischemia (p= 0.6599). Conclusion: Per this study, patients with Covid infection had increased mortality when compared to the general population admitted for acute aortic dissection. Aggressive treatment of Covid infection may reduce mortality as vigorous cough which is associated with Covid 19 can cause worsening aortic dissection.

An Atypical Presentation of X-linked Lymphoproliferative Disease type 1 Presenting with Seronegative Coccidioidomycosis

X-linked lymphoproliferative disease (XLP-1), an inborn error of immunity (IEI) caused by pathogenic variants in SH2D1A encoding signaling lymphocyte activation molecule-associated protein (SAP), is characterized by hemophagocytic lymphohistiocytosis (HLH), lymphoma, and hypogammaglobulinemia. We report the first known case of XLP-1 presenting with seronegative coccidioidomycosis. CaseA 13-year-old boy with persistent asthma, recurrent otitis media requiring four sets of tympanostomy tubes, chronic sinusitis, and Common Variable Immunodeficiency (CVID) presented with acute-on-chronic hypoxic respiratory failure. He had been off subcutaneous immunoglobulin (SCIg) replacement for 2 years. Sputum culture was positive for H. influenzae, treated with cefepime and azithromycin and supplemental oxygen for acute hypoxic respiratory failure. Fever persisted despite 48 hours of antibiotics. CT chest showed bronchiectasis with mediastinal, subcarinal and hilar adenopathy. Coccidioides immitis IgG and IgM were negative, but urine antigen was positive. There was no radiologic or cerebrospinal fluid evidence of disseminated coccidioidomycosis.Immunologic workup revealed undetectable IgG, IgA, IgM, and IgE (table 1). Lymphocyte subsets showed severe T and NK cell lymphopenia. Total B cell count was normal, but he had decreased CD19+27+ and transitional B cells, with absent switched memory B cells and no plasmablasts (table 1). Lymphocyte proliferation to mitogens/antigens was decreased. Serum ferritin was normal, and EBV PCR was negative. A targeted 429-gene panel identified a hemizygous variant of uncertain significance (VUS) in SH2D1A, c.82_102dup (p.Ser28_Ser34dup). SAP expression was absent in CD4+ T cells and NK cells with a bimodal expression in CD8+ T cells, suggesting possible mosaicism in this subset. He was diagnosed with X-linked lymphoproliferative disease 1 (XLP-1) and treated with fluconazole, trimethoprim-sulfamethoxazole prophylaxis, and IgG replacement (1 g/kg intravenous initially, then transitioned to weekly SCIg targeting an IgG >1000 mg/dL), with clinical improvement, resolution of fevers and acute hypoxia. He was referred for hematopoietic cell transplant evaluation.Coccidioidomycosis has not been described in a new diagnosis of XLP-1 and should be considered in this IEI. Coccidioidomycosis susceptibility has been reported in other IEIs including impaired interleukin-12/interferon-gamma axis signaling, STAT3 loss of function, chronic granulomatous disease, and recently cytidine triphosphate synthase 1 (CTPS1) deficiency.Table 1Patient’s immunologic variables compared to reference range. Absolute values are shownImmunologic VariablePatient ValuesReference RangeIgG<70 (L)<70 mg/dLIgA<15 (L)<15 mg/dLIgM<8 (L)<8 mg/dLIgE<1.5 (L)<1.5 IU/uLTotal CD4+ T Cells11 (L)570–2400 cells/uLTotal CD8+ T Cells63 (L)210–1200 cells/uLTotal CD19+ B cells173165–1154 cells/uLCD19+ CD24++ CD38++ (Transitional B Cells)0 (L)8–392 cells/uLCD19+CD24+CD38+ (Naïve B Cells)12159–1146 cells/uLCD19+CD27-(Naïve B cells)169140–2269 cells/uLCD19+ CD27+ CD38+ IgM- (Plasmablasts)0<30 cells/uLCD19+CD27+IgD-IgM- (Switched-memory B cells)0 (L)6–190 cells/uLCD16+ CD56+ (NK Cells)32 (L)78–470 cells/uLL – low

PO-04-028 INTERATRIAL SHUNT LEADING TO SEVERE HYPOXEMIA: A RARE COMPLICATION OF PACEMAKER-ASSOCIATED INFECTIVE ENDOCARDITIS

Pacemaker-lead-associated infective endocarditis is a serious complication with high morbidity and mortality. We present a case of persistent hypoxemia from significant right to left atrial shunting across the patent foramen ovale (PFO) as a result of pacemaker-lead-associated infective endocarditis with large vegetations. N/A A 56-year-old female with stroke, sleep apnea, diabetes mellitus, hypertension, and sick sinus syndrome with dual chamber pacemaker implantation, was admitted with acute hypoxic respiratory failure requiring high flow nasal cannula. A chest x-ray did not show any obvious etiology of hypoxemic respiratory failure. Arterial blood gas showed no hypercapnia ruling out hypoventilation as the cause of hypoxemia. A very high A-a gradient was noted, raising suspicion for shunting. Blood cultures were positive for staphylococcus capitis bacteremia. A transesophageal echocardiogram (TEE) showed several large vegetations (Image A) attached to the atrial and ventricular lead, tricuspid valve with associated severe tricuspid regurgitation, and a PFO (Image B) with a large right to left shunt as a result of large right-sided vegetations (Image C). A pacemaker extraction procedure was planned; however, there was a concern for paradoxical septic embolism across the PFO. As such, an ASD occluder device was temporarily placed across the PFO during the procedure to prevent right-to-left embolization. PFO occlusion dramatically improved hypoxemia during the procedure. The infected pacemaker system was then successfully extracted. The PFO occluder device was subsequently removed at the end of the case, given ongoing bacteremia and the risk of device seeding. The patient recovered well with the resolution of hypoxemia and was discharged however presented again one month later with a stroke. TEE exam showed a large echo-dense lesion straddling the atrial septum through the PFO, likely vegetation that embolized to the left circulation causing the stroke (Image D). The patient is currently awaiting cardiac surgery for definitive treatment once medically stable. Pacemaker-associated infective endocarditis can lead to mechanical complications, including tricuspid regurgitation and rarely shunting across the atria, causing severe hypoxemia as in our patient. There are no clear guidelines regarding the management of such atrial defects with shunting peri-device extraction to prevent systemic embolization of vegetations.

Noninvasive Oxygenation Strategies in Adult Patients With Acute Hypoxemic Respiratory Failure: A Systematic Review and Network Meta-Analysis

Several recently published randomized controlled trials have evaluated various noninvasive oxygenation strategies for the treatment of acute hypoxemic respiratory failure. Which available noninvasive oxygen strategies are effective for acute hypoxic respiratory failure? A systematic review of Medline, Embase, Cochrane CENTRAL, CINAHL, Web of Science, MedRxiv, and Research Square was conducted from inception to October 1, 2022. A random effects frequentist network meta-analysis was performed, and the results are presented using absolute risk difference per 1,000 patients. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to rate the certainty of the evidence. Mortality, invasive mechanical ventilation, duration of hospitalization and ICU stay, ventilator-free days, and level of comfort are reported. Thirty-six trials (7,046 patients) were included. It was found that helmet CPAP probably reduces mortality compared with standard oxygen therapy (SOT) (231 fewer deaths per 1,000; 95%CI, 126-273 fewer) (moderate certainty). A high-flow nasal cannula (HFNC) probably reduces the need for invasive mechanical ventilation (103.5 fewer events per 1,000; 95%CI, 40.5-157.5 fewer) (moderate certainty). All noninvasive oxygenation strategies may reduce the duration of hospitalization as compared with SOT (low certainty). Helmet bilevel ventilation (4.84days fewer; 95%CI, 2.33-7.36days fewer) and helmet CPAP (1.74days fewer; 95%CI, 4.49 fewer-1.01 more) may reduce the duration of ICU stay as compared with SOT (both low certainty). SOT may be more comfortable than face mask noninvasive ventilation and no different in comfort compared with an HFNC (both low certainty). A helmet interface for noninvasive ventilation probably reduces mortality and the risk of mechanical ventilation, as well as the duration of hospital and ICU stay. An HFNC probably reduces the risk of invasive mechanical ventilation and may be as comfortable as SOT. Further research is necessary to understand the role of these interfaces in acute hypoxemic respiratory failure.

Interrater Reliability of the 2015 Pediatric Acute Lung Injury Consensus Conference Criteria for Pediatric ARDS

Diagnostic guidelines for pediatric acute respiratory distress syndrome (PARDS) were developed at the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC). Although this was an improvement in creating pediatric-specific diagnostic criteria, there remains potential for variability in identification of PARDS. What is the inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS? What clinical criteria and patient factors are associated with diagnostic disagreements? Patients with acute hypoxic respiratory failure admitted from 2016-2021 who received invasive mechanical ventilation were retrospectively reviewed by two PICU physicians. Reviewers evaluated whether the patient met the 2015 PALICC definition of moderate-severe PARDS and rated their diagnostic confidence. Inter-rater reliability was measured using Gwet's Agreement Coefficient (AC1). 37 of 191 encounters had a diagnostic disagreement. Inter-rater reliability was "substantial" (AC1=0.74, 95% CI [0.65 - 0.83]). Disagreements were due to different interpretations of chest radiographs (56.8%), ambiguity in origin of pulmonary edema (37.8%), or lack of clarity if patient's current condition was significantly different from baseline (27.0%). Disagreement was more likely in patients who were chronically ventilated (OR 4.66, 95% CI [2.16-10.08], p<0.001), had a primary cardiac admission diagnosis (OR 3.36, 95% CI [1.18 - 9.53], p=0.02), or underwent cardiothoracic surgery during the admission (OR 4.90, 95% CI [1.60 - 15.00], p=0.005). Reviewers were at least moderately confident in their decision 73% of the time, however were less likely to be confident if the patient had cardiac disease or chronic respiratory failure. The inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS in this cohort was substantial, with diagnostic disagreements commonly due to differences in chest radiograph interpretations. Patients with cardiac disease or chronic respiratory failure were more vulnerable to diagnostic disagreements. More guidance is needed on interpreting chest radiographs and diagnosing PARDS in these subgroups.