Severe Respiratory Compromise Research Articles

Diagnostic Strategy in Idiopathic Diaphragmatic Paralysis

Unilateral diaphragmatic paralysis is a medical condition characterized by the impairment of either the right or left hemidiaphragm, resulting in an inability to contract effectively during inspiration. This condition may arise due to intrinsic diaphragmatic muscle dysfunction or a disruption in the neural input from the phrenic nerve to the affected hemidiaphragm. The etiology is diverse, with clinical manifestations varying from an absence of symptoms to severe respiratory compromise. This case study aims to review the assessment and management of unilateral diaphragmatic paralysis, highlighting the role of dynamic imaging techniques, such as diaphragmatic ultrasound, in the diagnosis, evaluation, and ongoing monitoring of patients with this condition.

Surgical therapy of a Fetal Lung Interstitial Tumor (FLIT) in an infant – A case report and review of surgical considerations

Congenital lung masses are rare and their clinical presentation is highly variable. If newborns present with respiratory distress immediately after birth, early surgical therapy can be necessary. Here, we present the case of a newborn with a very large left-sided lung tumor. The severe respiratory compromise warranted surgical resection at the age of 11 days. The surgery was conducted by an interdisciplinary team. Cardiopulmonary bypass was used to maintain hemodynamic stability. The postoperative histopathological workup identified the tumor as a Fetal Lung Interstitial Tumor (FLIT). The patient developed well and is doing fine 15 months after surgery.

Assessing the agreement of chronic lung disease of prematurity diagnosis between radiologists and clinical criteria

BackgroundChronic lung disease of prematurity (CLD) is the most prevalent complication of preterm birth and indicates an increased likelihood of long-term pulmonary complications. The accurate diagnosis of this condition is critical for long-term health management. Numerous definitions define CLD with different clinical parameters and radiology findings, making diagnosis of the disease ambiguous and potentially inaccurate.Methods95 patients were identified for this study, as determined by the diagnosis or confirmation of CLD in the impression of the radiologist’s report on chest x-ray. Pulmonary function and complications were recorded at multiple benchmark timeframes within each patient’s first few months of life and used for determining eligibility under each definition.ResultsEach clinical definition of CLD had a high sensitivity for patients identified to have CLD by radiologists, correctly fitting over 90% of patients. Most patients included required invasive mechanical ventilation or positive pressure ventilation at 36 weeks postmenstrual age, indicating patients with radiographically confirmed CLD tended to have more severe disease. Radiologists tended to diagnose CLD before 36 weeks postmenstrual age, a timepoint used by multiple standard clinical definitions, with cases called earlier fitting under a larger percentage of definitions than those called later.ConclusionsRadiologists tend to diagnose CLD in young patients with severe respiratory compromise, and can accurately diagnose the condition before developmental milestones for clinical definitions are met.

Relationship between maternal arterial and foetal cord carbon dioxide tension and neonatal outcome in critically ill pregnant women at delivery.

No studies have evaluated the relationship between maternal arterial partial pressure of carbon dioxide (mPaCO2) and umbilical cord venous partial pressure of carbon dioxide (PCO2) in critically ill pregnant women at delivery. Based on the studies in healthy pregnant women, an mPaCO2 target of ≤50 mmHg is a suggested threshold during mechanical ventilation in critically ill parturients. We evaluated the relationship between mPaCO2 and neonatal cord gases in critically ill parturients at delivery as the primary objective. The relationship between mPaCO2 and APGAR scores at delivery was also analysed as a secondary objective. Maternal and neonatal cord gas data at delivery and APGAR scores were obtained by a retrospective chart review of 25 consecutive parturients with severe respiratory compromise who were delivered during mechanical ventilation. Linear regression was used to assess the relationship between mPaCO2 and umbilical artery and vein PCO2 and between mPaCO2 and APGAR scores at 1 and 5 min. There was a positive correlation between mPaCO2 and neonatal cord venous PCO2 (P = 0.013). Foetal venous PCO2 exceeded predelivery mPaCO2 by 17.5 (7.5) mmHg. There was an inverse relationship between mPaCO2 and neonatal APGAR scores at 1 and 5 min (P = 0.006 and P = 0.007, respectively). Foetal cord venous PCO2 can be predicted if mPaCO2 values are known. Unlike in healthy pregnant women, there was an inverse relationship between rising mPaCO2 levels and neonatal APGAR scores in critically ill pregnant women who had several associated compounding factors.

Heart Rate Variability Measured from Wearable Devices as a Marker of Disease Severity in Tetanus.

Tetanus is a disease associated with significant morbidity and mortality. Heart rate variability (HRV) is an objective clinical marker with potential value in tetanus. This study aimed to investigate the use of wearable devices to collect HRV data and the relationship between HRV and tetanus severity. Data were collected from 110 patients admitted to the intensive care unit in a tertiary hospital in Vietnam. HRV indices were calculated from 5-minute segments of 24-hour electrocardiogram recordings collected using wearable devices. HRV was found to be inversely related to disease severity. The standard deviation of NN intervals and interquartile range of RR intervals (IRRR) were significantly associated with the presence of muscle spasms; low frequency (LF) and high frequency (HF) indices were significantly associated with severe respiratory compromise; and the standard deviation of differences between adjacent NN intervals, root mean square of successive differences between normal heartbeats, LF to HF ratio, total frequency power, and IRRR, were significantly associated with autonomic nervous system dysfunction. The findings support the potential value of HRV as a marker for tetanus severity, identifying specific indices associated with clinical severity thresholds. Data were recorded using wearable devices, demonstrating this approach in resource-limited settings where most tetanus occurs.

Outcomes and Complications Associated With Caudal Thoracic and Abdominal Air Sac Cannulation in 68 Birds.

Air sac cannulation is used both as an emergency procedure in avian patients with severe upper respiratory compromise, as well as a means of routine ventilation for surgery of the head and neck. The objective of this retrospective study was to describe and quantify the complications associated with air sac cannulation in birds. Medical records were retrieved for all patients that underwent caudal thoracic or abdominal air sac cannulation at a single center between August 2004 and October 2020. Patient signalment, indication for air sac cannulation, location of air sac cannula (ASC) placement, occurrence and category of complications encountered, and survival data were recorded. Eighty-four ASCs were placed in 68 birds across 6 orders; 95.2% (80/84) of cases survived general anesthesia for initial ASC placement. The side and position of ASC placement were known in 33.3% (28/84) and 21.4% (18/84) of cases, respectively. Survival to ASC removal was known in 91.3% (73/80) of cases; 43 (58.9%) of these 73 cases survived to ASC removal. Complications were observed in 32.5% (26/80) of cases, and 11.5% (3/26) of cases died as a direct result of the complication. The most common reported ASC complication was loss of patency in 23.8% (19/80) of cases. Increased likelihoods for complications were seen in cases where exercise intolerance (P = 0.04) or abnormal respiratory sounds (P = 0.04) were reported at presentation. Increased likelihoods for survival to ASC removal were seen with intercostal placements (P = 0.049) and peri-interventional antibiotic therapy (P = 0.005). Decreased likelihood for survival to ASC removal was seen in cases where voice change was reported at presentation (P = 0.02). This study demonstrates a moderate risk of ASC complication, with a guarded overall prognosis for survival to ASC removal.

Prenatal Diagnosis of Costello Syndrome Using Noninvasive Prenatal Single Gene Testing With Maternal Blood

Introduction Costello syndrome (CS) is a rare disorder that affects multiple organ systems, which is usually diagnosed postnatally, except for 2 cases diagnosed prenatally from chromosome analysis by amniocentesis. We present the first case of prenatally diagnosed CS via maternal blood testing. Case Description A 38-year-old woman was referred for genetic screening at 28 weeks of gestational age (GA) due to polyhydramnios and shortened limbs seen on prenatal ultrasound. Cell-free DNA, noninvasive prenatal single gene screening was positive for G12S HRAS mutation, which is indicative of CS. The infant was delivered via elective repeat cesarean section at 36 weeks and 6 days GA, was admitted to the neonatal intensive care unit for respiratory distress. Physical examination was significant for macrocephaly, wide depressed nasal bridge, short neck, rhizomelic limb shortening, micropenis, and bilateral equinovarus deformity of the feet. Echocardiography on the first day showed severe pulmonary hypertension. Brain MRI showed a possible cavernous mass lesion and small arachnoid cyst over the left cerebellar hemisphere. Postnatal gene-targeted testing confirmed CS diagnosis with pathogenic variants. The infant was managed for respiratory distress, hypoglycemia, jaundice, and feet deformities. He was subsequently transferred to another hospital at 45 weeks of age for gastrostomy tube placement due to persistent difficulty with oral feeding. Discussion CS affects multiple organ systems. Clinical presentations includes short stature; macrocephaly; coarse facial features, loose and soft skin; hypotonia and joint laxity; cardiac involvement with congenital heart defect, feeding difficulty, and developmental delay. The phenotypic spectrum is wide and can range from mild features to early lethal complications mostly as a result of severe progressive Hypertrophic Cardiomyopathy (HCM) and respiratory compromise. CS is an autosomal dominant genetic disorder caused by mutations in the HRAS gene, but almost all cases have new mutations with no family history. Disease course depends on cardiac and predisposition to benign and malignant tumor complications. Treatment requires a multidisciplinary team directed toward the specific clinical findings. Conclusion To our knowledge, this is the first reported case of prenatally diagnosed CS via maternal blood testing. Molecular diagnosis in the prenatal period allows neonatal care providers to prepare for potential complications in the postnatal period.

Effective prognostic and clinical risk stratification in COVID-19 using multimodality biomarkers.

In acute COVID-19 patients, effective clinical risk stratification has important implications on treatment and therapeutic resource distribution. This article reviews the evidence behind a wide range of biomarkers with prognostic value in COVID-19. Patient characteristics and co-morbidities, such as cardiovascular and respiratory diseases, are associated with increased mortality risk. Peripheral oxygen saturation and arterial oxygenation are predictive of severe respiratory compromise, whilst risk scores such as the 4C-Score enable multi-factorial prognostic risk estimation. Blood tests such as markers of inflammation, cardiac injury and D-dimer, and abnormalities on electrocardiogram are linked to inpatient prognosis. Of the imaging modalities, lung ultrasound and echocardiography enable bedside assessment of prognostic abnormalities in COVID-19. Chest radiograph (CXR) and computed tomography (CT) can inform about prognostic pulmonary pathologies, whilst cardiovascular CT detects high-risk features such as coronary artery and aortic calcification. Dynamic changes in biomarkers, such as blood tests, CXR, CT and ECG findings, can further inform about disease severity and prognosis. Despite the vast volumes of existing evidence, several gaps exist in our understanding of COVID-19 biomarkers. Firstly, the pathophysiological basis on which these markers can foretell prognosis in COVID-19 remains poorly understood. Secondly, certain under-explored tests such as thoracic impedance assessment and cardiovascular magnetic resonance imaging deserve further investigation. Lastly, the prognostic value of most biomarkers in COVID-19 are derived from retrospective analyses. Prospectively studies are required to validate these markers for guiding clinical decision-making and to facilitate their translation into clinical management pathways. This article is protected by copyright. All rights reserved.

Normal Outcome With Prenatal Intervention for Riboflavin Transporter Defect

BackgroundRiboflavin transporter deficiency is a rare but severe neurometabolic disorder. MethodsWe report two siblings with pathogenic variants in SLC52A3 gene, resulting in riboflavin transporter 3 deficiency. ResultsThe first sibling was diagnosed at age 11 months with severe respiratory compromise and regression of developmental milestones. His symptoms significantly improved with riboflavin supplementation therapy. The younger sibling was diagnosed by antenatal genetic analysis; riboflavin supplementation was initiated in utero and continued from birth. Now at age two years, he remains clinically asymptomatic despite genetic confirmation of riboflavin transporter deficiency. ConclusionsAntenatal riboflavin supplementation is a safe and effective treatment for the prevention of symptomatic manifestations of riboflavin transporter deficiency.

Awake Prone Positioning in Nonintubated Patients With Acute Hypoxemic Respiratory Failure.

Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed. To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients' safety, comfort, and tolerance. This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search. The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures. Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients' refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should optimize pain control, communication, patient comfort, patient adherence, and correct positioning.

Severity of COVID-19 Disease in Pregnant and Nonpregnant Females of Reproductive Age Group: A Preliminary Comparative Study

Objectives: This study was conducted to compare the disease severity of COVID-19 in pregnant and nonpregnant females of reproductive age group and to evaluate the effect of COVID-19 on neonatal outcome. Materials and Methods: The present prospective observational study was conducted at a tertiary care center in northern India over a period of 6 months. Females of reproductive age group (15–44 years) that were admitted in COVID isolation ward with reverse transcription–polymerase chain reaction-positive COVID-19 disease were included in the study and followed till discharge. Results: Among the 60 females of reproductive age group, 41.67% (25) were pregnant and 58.34% (35) were nonpregnant. The median duration of hospitalization among pregnant and nonpregnant females was 9 and 8.5 days, respectively. The severity of infection among pregnant and nonpregnant females was as follows: asymptomatic + mild disease 96% (24) and 77.14% (27) and moderate + severe disease 4% (1) and 22.86% (8), respectively. There were no maternal mortalities. Forty percent (10) of pregnant females had lower segment cesarean section (LSCS) and 32% (8) had normal vaginal delivery. There were 8 preterm, 6 full-term, 3 early-term, and 1 late-term deliveries. Twelve newborns had normal birth weight, 4 were low birth weight (LBW), 1 was very LBW, and 2 intrauterine deaths IUD were reported. No case of neonatal death or neonatal asphyxia was reported. Conclusion: In comparison to nonpregnant women with COVID-19 pneumonia, the infected pregnant females had mild or no respiratory symptoms, and none developed severe respiratory compromise or required intensive care. Preterm delivery, LSCS, and LBW were common in COVID-19-infected females.

Impact of sternal fixation on patient outcomes: A case matched review.

Sternal fractures are debilitating injuries often resulting in severe pain and respiratory compromise. Surgical fixation of sternal fractures is gaining popularity as a treatment modality for sternal fractures. Unfortunately, little literature exists on this topic. This study looks to further examine the benefits of sternal fixation (SF), hypothesizing SF results in improved pain, improved respiratory function, and decreased opioid use. Retrospective review was performed between patients with sternal fractures who underwent nonoperative management (NOM) versus operative SF. Case matching was used to construct an artificial control group matched on age and Injury Severity Score using a 1:1 ratio of treatment to control. Exclusion criteria were age younger than 18 years. Outcomes of interest included mean pain score, total opioid requirements (in morphine milliequivalents) within 24 hours of discharge, intensive care unit and hospital length of stay (LOS), and incentive spirometry percent predicted value at discharge. Dependent variables were analyzed using t test, and Injury Severity Score was analyzed using the sign test. Statistical significance was set at p < 0.05. Fifty-eight patients from the SF cohort were matched with 58 patients from the NOM cohort. The average age was 59.8 years for the SF group and 62.2 years for the NOM group. Injury Severity Score was matched at 9 for both cohorts. Although pain scores were similar for both cohorts, the SF group required significantly less opioids at discharge (62.1 vs. 92.2 morphine milliequivalents; p = 0.007). In addition, the SF cohort demonstrated significantly improved respiratory function per incentive spirometry percent predicted value at discharge (75.5% vs. 59.9%; p < 0.001). Intensive care unit LOS and hospital LOS were similar between cohorts. Despite similarities in pain scores, intensive care unit LOS, and hospital LOS, SF was associated with decreased opioid requirements and improved respiratory function at discharge in this study. Therapeutic/Care Management; Level IV.

813 Giant Inginoscrotal Hernias: Considerations for Optimisation of Patient Outcomes

Abstract Giant inguinoscrotal hernias (GISH) are unique and complex surgical challenges due to their rare presentation in the western world and the high risk of post-repair complications such as abdominal compartment syndrome and multi-organ failure. They are defined as inguinoscrotal hernias that extend below mid inner thigh. Due to the potential complications, optimising these patients throughout their hospital admission is crucial. Here, we present a 30-year-old Caucasian male who was admitted to our surgical unit in a public health system with a painful giant inguinoscrotal hernia, the complications he encountered and the lessons we learned. His CT scan demonstrated a strangulated hernia, for which he underwent an emergency open mesh repair. Post-operatively, he experienced severe respiratory compromise due to lower lobe collapse, which was attributed to the concomitant pneumonia present on admission, sub-optimal utilisation of analgesia and loss of domain. The complications were compounded by anxiety about medical intervention which delayed investigations and treatments. We highlight the importance of early identification of GISH, ensuring cardio-respiratory function is optimised pre- and post-operatively, and a multi-disciplinary approach to improve compliance with treatment including extensive counselling to increase engagement with healthcare services.

Anesthetic management of tracheo-esophageal fistula

: The anesthetic management of a neonate diagnosed to have tracheoesophageal fistula (TEF) with or without esophageal atresia (EA) is challenging, especially due to abnormally connected airway and esophagus interfering with patency of the airway and compromising ventilation. The anatomical variations regarding this congenital anomaly and the associated anomalies in various systems, determines both the surgical intervention and the anesthetic management. An urgent surgical intervention may be required within the first 48 hours after birth in case of severe respiratory compromise. On the other hand, a staged approach may be preferred including a gastrostomy in case of either the presence of low-birth-weight, isolated EA or more critical co-morbidities. A laryngotracheobronchoscopy is often performed prior to definitive surgery in order to identify the location and size of fistula, as well as, secondary upper airway anomalies. In the preoperative period, airway must be secured, and optimizing the status of the neonate in terms of other system functions should have a high priority. Intraoperatively, regardless of the agents used, the anesthetic management should focus on adequate depth of anesthesia, and adequate ventilation and oxygenation. The coordination between the anesthetist and the surgeon is crucial during the surgery in order to secure adequate ventilation and oxygenation. The associated anomalies should be considered as the main determinants of perioperative mortality and morbidity, hence, anesthetic management should also focus on intraoperative maintenance of preoperatively optimized functions. The analgesic management in the postoperative period is often provided by multimodal analgesic use.

Endotracheal Tuberculous Stenosis: Ventilation Rescue and Bronchography Guided Stenting

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Real-Life Use of Tocilizumab in the Treatment of Severe COVID-19 Pneumonia.

Introduction Coronavirus disease 2019 (COVID-19) can progress to severe respiratory compromise and lead to mortality due to induction of cytokine storm. Tocilizumab (TCZ) is approved by the FDA for the treatment of cytokine release syndrome (CRS). This study aims to analyze the outcomes among patients who received TCZ in the United Arab Emirates. Methods A retrospective cohort study was conducted among COVID-19 patients who received TCZ in a tertiary care hospital from May 2020 to August 2021. For analysis, patients were divided into two groups based on survival and clinical improvement. Results Overall, 80% of patients receiving TCZ were discharged by day 28. There was a gradual improvement in oxygen requirements in our patients with a majority of them on room air by day 28. Age more than 50 years (P=0.034) and comorbidities such as cardiovascular disease (CVD) (P=0.002) and renal insufficiency (P=0.013) were significantly associated with mortality. Discussion. In our analysis, patients who were mechanically ventilated at the time of administration of TCZ had a significantly higher risk of death by day 28. In both survived and improved groups, younger patients had better outcomes than older patients. Patients who received TCZ earlier during therapy from the onset of symptoms had better survival outcomes. There was only one death among 14 patients who received vaccination. There was no significant difference in mortality among patients with comorbidities such as diabetes, hypertension, dyslipidemia, obesity, and pulmonary diseases, hypothesizing that administration of TCZ improves the outcomes in COVID-19 patients with these comorbidities.

094 Home mechanical ventilation (HMV) in motor neurone disease: a 12 year single centre cohort study

HMV support for patients living with motor neuron disease MND is recommended by NICE to improve quality of life and survival. Although there are intermediate term outcome data, long-term data are sparse.From 2007 to 2019, 413 patients (246 male) received HMV; 310 have died (75.0%). Age at onset was 61.4 ±12.4 years. The duration between onset of symptoms and diagnosis was 13 months (0–104) and between onset of symptoms and referral was 29 months (0–300). At presentation, 37% patients had established res- piratory failure with a further 13% exhibiting incapacitating breathlessness. Survival was 11.9 ± 18.5 months after commencing HMV although the duration of HMV support for those still alive was 26.6 ± 30.5 months. 9.0% received long-term tracheostomy; 53% had gastrostomy feeding tubes and 25.7% cough assist device.These data show a delay both in establishing a definitive diagnosis of MND and in referring for specialist support. Delaying referral until severe respiratory compromise has developed may reduce the sympto- matic benefits of NIV. Prolonged survival with HMV support is possible but early intervention is essential to optimise clinical management. The data and clinical experience serve to emphasise the importance of early referral for specialist respiratory assessment and management.robinhoward@nhs.net

Intratracheal oxygen administration increases FIO2 and PaO2 compared with intranasal administration in healthy, standing horses.

To evaluate the efficacy of 2 different oxygen delivery strategies-intranasal and tracheal insufflation-on the inspired fraction of oxygen (FIO2) in standing horses and to determine the time needed for arterial oxygen partial pressure (PaO2) equilibration. 6 healthy adult horses. In this blinded, randomized crossover design study, horses were randomly assigned to receive oxygen via nasal cannula (group N) or transcutaneous tracheal catheter (group T). After placement of venous and arterial catheters, FIO2 was measured through a catheter placed into the distal portion of the trachea. After baseline measurements were obtained, horses received oxygen at up to 25 mL/kg/min for 1 hour via either intranasal or intratracheal catheter. The FIO2 and PaO2 were recorded at 5, 10, 15, 20, 25, 30, 45, and 60 minutes during and 5, 10, 15, 20, and 30 minutes after oxygen insufflation. Data were analyzed by use of a 2-way repeated measures ANOVA with Tukey-Kramer post hoc testing for pairwise comparisons (P < 0.05). During oxygen administration, FIO2 and PaO2 increased significantly when compared with baseline, resulting in significantly higher values for group T (37.7 ± 2.4%; 214.6 ± 18 mm Hg) than for group N (34.3 ± 3.9%; 184.1 ± 11 mm Hg). The equilibration time was less than 10 minutes. Intratracheal oxygen administration resulted in better oxygenation than nasal insufflation and should therefore be considered in standing horses that are experiencing severe respiratory compromise. The equilibration between FIO2 and PaO2 is rapid in adult horses.

Abstract #1185163: Severe Respiratory Compromise due to Primary Thyroid Lymphoma

Primary thyroid lymphoma is a rare condition making up 5% of thyroid malignancies and 2.5% of all lymphomas. Most primary thyroid lymphomas are diffuse large B-cell lymphoma, which is the most aggressive type.

COVID-19 Vaccine Triggered Rejection in Lung Transplant Recipients: A Case Series

PurposeAnti-severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) vaccination is recommended by AST, ISHLT, and CDC in all transplant recipients. Lung transplant recipients (LTR) are at a higher risk of developing severe symptoms due to higher immunosuppression (IS) and baseline compromised graft function. Limited antibody response to messenger RNA (mRNA) vaccines has been reported in LTR, with the majority mounting a response after the 2nd dose. In this series, 3 patients developed new and significant respiratory compromise after their 2nd vaccine dose consistent with antibody mediated rejection (AMR). To our knowledge, this is the first published case series of vaccine induced rejection in LTR.MethodsRetrospective chart review of our cohort showed 46% fully vaccinated and an additional 2.5% partially vaccinated patients. Three fully vaccinated patients with approved mRNA vaccines (2 Moderna, 1 Pfizer-BioNTech) were identified after developing severe respiratory compromise post 2nd vaccine dose. Evaluation revealed AMR as the underlying etiology.ResultsAll patients were female, ages 50-70 years old, between 6 months and 2 years post-transplant. No previous rejection episodes. All were on standard IS as per institution protocols. Two were hospitalized with hypoxic respiratory failure within 2 weeks of their 2nd vaccine dose. The 3rd was seen at clinic for milder similar symptoms, later progressing and requiring supplemental oxygen (O2) and hospitalization. Imaging showed new lung infiltrates, infectious work up was negative. Biopsies did not show any cellular rejection. All developed new DSAs and received treatment for AMR with plasmapheresis, IVIg, and Rituximab. Two recovered their lung function and are off supplemental O2, the 3rd did not and is re-listed for transplant.ConclusionWhile LTR have a diminished response to SARS-CoV-2 vaccines making them more vulnerable to the disease, their immune system's response may not always be clear. We report three cases of patients developing severe AMR from new DSAs that appear to be triggered by the COVID-19 vaccine. This vaccine responses should be collected in a database where each case can be investigated to help better understand the mechanism behind them and hopefully identifying LTR at risk. This can then be used to modify vaccination strategies and aid in preventing adverse outcomes in this vulnerable group of patients.