SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Refractory wheezing and pneumonia in patients with chronic obstructive pulmonary disease (COPD) should prompt further evaluation for alternative etiologies. Endobronchial obstruction may mimic classic signs and symptoms of COPD exacerbation. CASE PRESENTATION: A 66-year-old male former smoker with COPD presented to the emergency department (ED) with progressive dyspnea, fatigue, and productive cough after failing outpatient treatment with antibiotics for pneumonia. He was hypoxic to 85% on room air. Chest x-ray demonstrated right middle lobe pneumonia. An infectious evaluation including urinary antigens, viral studies, and respiratory cultures was negative. He quickly improved with intravenous antibiotics and steroids and was discharged the following day on oral antibiotics and a steroid taper. Four days later, he presented to the ED with progressive dyspnea and new orthopnea necessitating non-invasive positive pressure ventilation. Physical examination revealed accessory muscle use, diffuse expiratory wheezing, and diminished breath sounds. Laboratory evaluation was significant only for leukocytosis to 30.0 x 103 μL. Computed tomography scanning of the chest demonstrated a 2 cm endobronchial mass at the carina causing almost complete obstruction of the mainstem bronchi. His condition rapidly deteriorated, and awake femoral cannulation for venovenous extracorporeal membrane oxygenation (VV ECMO) was performed. Rigid bronchoscopic tumor resection was then performed under general anesthesia. Purulent secretions were aspirated from throughout the endobronchial tree. Airway patency was completely restored to the left mainstem bronchus and partially restored to the right mainstem bronchus. ECMO was weaned off immediately after resection of the mass. Pathology returned as invasive squamous cell carcinoma, and treatment with concurrent chemotherapy and radiation was initiated. DISCUSSION: Central airway obstruction (CAO), especially when it involves the trachea or carina, poses a significant management challenge. VV ECMO may be required to preserve ventilatory function in these patients during periods of complete airway occlusion as the obstruction is resected. ECMO support permits additional time for the operator to plan and implement the resection strategy for a life-saving airway procedure. A multidisciplinary team is required for management of these complex cases. Preemptive or nonemergent ECMO cannulation should be considered in patients with significant central airway obstruction. Data on the utility and safety of VV ECMO for rigid bronchoscopic resection of CAO is limited to case series. Future research is needed to assess the impact of VV ECMO on outcomes in these cases. CONCLUSIONS: Large carinal or distal tracheal tumors pose significant management challenges. ECMO may be required to ensure adequate oxygenation and ventilation until airway patency can be restored. Reference #1: J Crit Care. 2013 Oct;28(5):669-74 Reference #2: J Thorac Dis. 2016 Nov; 8(11): 3401–3413 DISCLOSURES: No relevant relationships by Rasika Chepuri, source=Web Response course relationship with Pinnacle Biologic Please note: $1001 - $5000 Added 03/13/2019 by Jonathan Kurman, source=Web Response, value=Travel Speaker/Speaker's Bureau relationship with Biodesix Please note: $5001 - $20000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Honoraria Consultant relationship with Medtronic Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Consulting fee Consultant relationship with Level EX Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Consulting fee educational course relationship with Pinnacle Biologics Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Travel<br Speaker/Speaker's Bureau relationship with American Medical Forum Please note: $1001 - $5000 Added 03/18/2019 by Jonathan Kurman, source=Web Response, value=Honoraria