Tension Physiology Research Articles

Community-Acquired Candida albicans Empyema Leading to Tension Physiology: A Case Report.

A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described. In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition. While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Tension Pyopneumothorax in an Immunocompetent Adolescent: A Case Report.

Tension pyopneumothorax is a rare, life-threatening condition that occurs as a complication of intrathoracic infection or bronchopleural fistula. In the few cases reported in the literature, the patients typically have multiple comorbidities, underlying lung disease, and/or an immunocompromised state. This case describes tension pyopneumothorax in a previously healthy adolescent male with no existing risk factors for this disease. After emergent stabilization and admission, surgical exploration of the chest revealed no fistulas or pleural defects. Extensive workup did not show any underlying risk factors for development of this condition. This case of pyopneumothorax with progression to tension physiology is exceedingly rare. Uniquely, the patient had no underlying medical or anatomical predisposition to developing this condition. The case also emphasizes pediatric patients' capacity to compensate in the setting of critical illness.

Pneumopericardium following severe thoracic trauma

BackgroundTraumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication. Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury. MethodsWe conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management. ResultsOver a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18–77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC. ConclusionsTraumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.

Penetrating firearm tracheal injury with cardiac arrest due to tension pneumopericardium

Firearm-associated tracheal injuries occur infrequently and as such there is no standard approach. We present a case of tension pneumopericardium due to a firearm-associated tracheal injury which was successfully repaired through an anterior midline sternotomy approach. In hemodynamically unstable patients who cannot tolerate posterolateral approaches, the anterior midline sternotomy approach to the airway should be considered. We demonstrate that this approach can provide adequate access for decompression of tension physiology and repair of airway injury.

Utilization and Outcomes of Observation for Spontaneous Pneumothorax at an Integrated Health System

IntroductionThough limited, recent evidence supports observation rather than intervention for spontaneous pneumothorax management. We sought to compare the utilization and outcomes between observation and intervention for patients with primary and secondary spontaneous pneumothoraces. MethodsA retrospective cohort study of all adults presenting to Kaiser Permanente Northern California emergency rooms with spontaneous pneumothorax from 2016 to 2020 was performed. Those with prior pneumothoraces, tension physiology, bilateral pneumothoraces, effusions, and prior thoracic procedures or surgery on the affected side were excluded. Groups included observation versus intervention. Baseline clinicodemographic variables and outcomes were compared. Treatment was considered successful if further interventions were not required for pneumothorax resolution. Wilcoxon rank-sum tests, chi-square tests, Fischer exact tests, and multivariable logistic regression models were performed. ResultsOf the 386 patients with primary spontaneous pneumothorax, age, race/ethnicity, body mass index, smoking status, and the Charlson comorbidity index were not different between treatment groups. Of 86 patients with secondary spontaneous pneumothorax, age, gender, and smoking status were not different between treatment groups. Among patients with primary pneumothoraces, 83 underwent observation while 303 underwent intervention. The success rate was 92.8% for observation and 60.4% for intervention (P < 0.0001). Among patients with secondary pneumothoraces, 15 underwent observation while 71 underwent intervention, with a successful rate of 73.3% for observation and 32.4% for intervention (P = 0.003). ConclusionsGiven the high success rates for observation of both small and moderate primary and secondary pneumothoraces, observation should be considered for clinically stable patients. Observation may be the superior choice for decreasing morbidity and healthcare costs.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.

We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Urgent decompression of tension pneumomediastinum in a patient to relieve elevated intracranial pressure: a case report

Background: Timely recognition and intervention for venous outflow obstruction due to intrathoracic pathology are critical for controlling elevated intracranial pressure.Case Report: A 26-year-old man with pectus excavatum and a posterior fossa tumor requiring biopsy, decompression, and cerebrospinal fluid diversion developed pneumomediastinum following intubation with tension physiology and progressive elevation of intracranial pressure. Emergent tracheostomy was performed to decompress intrathoracic pressure, augment venous return, and ultimately expedite the patient’s definitive cancer therapy. Conclusion: Recognition of the mediastinal pathology leading to venous obstruction may be required for the management of malignant intracranial hypertension. Tracheostomy may be a means to decompress mediastinal pressure and augment venous outflow in rare cases of pneumomediastinum with tension physiology.

POSTERIOR PNEUMOTHORAX IN A PATIENT WITH COVID-19 ON ECMO: A CASE REPORT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Pneumothoraces are a known complication of SARS-CoV-2, but the reported rate varies between studies. Posterior pneumothoraces are extremely uncommon with few published case reports. CASE PRESENTATION: A 51-year-old woman presented with dyspnea, fever, pulmonary infiltrates, and positive SARS-CoV2 nasopharyngeal PCR. Her respiratory status deteriorated, she was intubated, and she ultimately required VV-ECMO cannulation. Her hospital course was complicated by DVT, pulmonary aspergillosis, E coli pneumonia, and left sided hydropneumothorax treated with chest tube drainage. On hospital day 56, the patient abruptly developed a vasopressor requirement with a rapid elevation in lactate. CXR identified a large left air space. POCUS of the chest was remarkable for A-line artifact and absent lung sliding of the left posterior chest. CT confirmed a posterior pneumothorax. A 14Fr small-bore chest tube was placed by IR with improvement in the size of the pneumothorax and hemodynamic status, shown on image C below. The patient’s course was further complicated by right-sided hydropneumothorax due to E. coli and E. faecalis empyema that was treated with 14Fr chest tube drainage. She gradually improved, was decannulated from VV-ECMO, and on hospital day 107 was discharged to an acute rehabilitation facility with all chest tubes removed. DISCUSSION: Here we describe a patient’s hospital course complicated by repeated pneumothoraces including a left posterior loculated pneumothorax causing tension physiology. CONCLUSIONS: Available literature suggests pneumothorax may occur in 11% of COVID-19 patients treated with ECMO. The proper management of these patients is still unclear and clinicians must take these complications into account when directing care. DISCLOSURE: Nothing to declare. KEYWORD: Pneumothorax

Comparing a Novel Hand-Held Device for Chest Tube Insertion to the Traditional Open Tube Thoracostomy for Simple Pneumothorax in a Porcine Model.

Tube thoracostomy is the most effective treatment for pneumothorax, and on the battlefield, is lifesaving. In combat, far-forward adoption of open thoracostomy has not been successful. Therefore, the ability to safely and reliably perform chest tube insertion in the far-forward combat theatre would be of significant value. The Reactor is a hand-held device for tube thoracostomy that has been validated for tension pneumothorax compared to needle decompression. Here we investigate whether the Reactor has potential for simple pneumothorax compared to open thoracostomy. Treatment of pneumothorax before tension physiology ensues is critical. Simple pneumothoraces were created in 5 in-vivo swine models and confirmed with x-ray. Interventions were randomized to open technique (OT, n = 25) and Reactor (RT, n = 25). Post-procedure radiography was used to confirm tube placement and pneumothorax resolution. Video Assisted Thoracoscopic Surgery (VATS) was used to evaluate for iatrogenic injuries. 50 chest tubes were placed, with 25 per group. There were no statistical differences between the groups for insertion time, pneumothorax resolution, or estimated blood loss (p = .91 and .83). Injury rates between groups varied, with 28% (n = 7) in the Reactor group and 8% (n = 2) the control group (p = .06). The most common injury was violation of visceral pleura (10%, n = 5, both groups) and violation of the mediastinum (8%, n = 4, both groups). The Reactor device was equal compared to open thoracostomy for insertion time, pneumothorax resolution, and injury rates. The device required smaller incisions compared to tube thoracostomy and may be useful adjunct in simple pneumothorax management.

Needle Decompression of Tension Pneumoperitoneum: A Case Report.

IntroductionTension pneumoperitoneum is rarely encountered in the emergency department but can have disastrous effects on the body when it is. However, an emergency physician has skills that can be readily applied to needle decompress the abdomen for rapid stabilization.Case ReportA 42-year-old male arrived via ambulance after a likely overdose with mental status improvement following naloxone administration. He was found to be in respiratory distress due to a rigid, distended abdomen that required intubation for stabilization. Computed tomography imaging showed significant pneumoperitoneum with tension physiology. Surgery consultation was unable to intervene immediately, and needle decompression with an angiocatheter was performed at the bedside with immediate ventilatory improvement.ConclusionTension pneumoperitoneum is a rare but potentially disastrous consequence of overdose secondary to emesis and rupture of the gastric wall. Needle decompression is a skillset already in the emergency physician’s toolbox and can be applied for emergency stabilization of a tension pneumoperitoneum with proper forethought and technique.

Plexin-B2 orchestrates collective stem cell dynamics via actomyosin contractility, cytoskeletal tension and adhesion

During morphogenesis, molecular mechanisms that orchestrate biomechanical dynamics across cells remain unclear. Here, we show a role of guidance receptor Plexin-B2 in organizing actomyosin network and adhesion complexes during multicellular development of human embryonic stem cells and neuroprogenitor cells. Plexin-B2 manipulations affect actomyosin contractility, leading to changes in cell stiffness and cytoskeletal tension, as well as cell-cell and cell-matrix adhesion. We have delineated the functional domains of Plexin-B2, RAP1/2 effectors, and the signaling association with ERK1/2, calcium activation, and YAP mechanosensor, thus providing a mechanistic link between Plexin-B2-mediated cytoskeletal tension and stem cell physiology. Plexin-B2-deficient stem cells exhibit premature lineage commitment, and a balanced level of Plexin-B2 activity is critical for maintaining cytoarchitectural integrity of the developing neuroepithelium, as modeled in cerebral organoids. Our studies thus establish a significant function of Plexin-B2 in orchestrating cytoskeletal tension and cell-cell/cell-matrix adhesion, therefore solidifying the importance of collective cell mechanics in governing stem cell physiology and tissue morphogenesis.

A BRIEF HIATUS: PARAESOPHAGEAL HERNIA REPAIR COMPLICATED BY THORACIC HERNIA SAC

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Paraesophageal herniation (PH) is the displacement of abdominal viscera, particularly the stomach, through the diaphragm into the thorax. Surgical fundoplication can infrequently lead to post-operative complications. We present a unique case of stage IV PH complicated by post-fundoplication insufflated hernia sac causing hemodynamic instability. CASE PRESENTATION: A 77-years-old woman with hypertension presented with dysuria and abdominal discomfort and was found to have hypokalemia, atrial fibrillation (AF), and pyuria. A stage IV PH was noted on computed tomography (CT). She underwent laparoscopic Nissen fundoplication for hernia repair. Postoperatively, she had worsening chest pain, dyspnea and tachycardia. CT scan revealed a large hernia sac with air-fluid level within the thorax causing cardiac shift and compression. The patient was intubated for worsening dyspnea and started on pressors for refractory hypotension. A pigtail catheter was placed under radiographic guidance into the displaced hernia sac with decompression of air and retrieval of fluid with rapid improvement in hemodynamics and cardiac shift. Fluid analysis showed low cell counts and negative cytology with yeast in culture. As tube feeds were introduced, the formulation drained through the hernia sac catheter with an elevated fluid amylase level of 895 raising concern for an esophageal leak. The patient was extubated to high-flow nasal cannula but intermittent hypotension, dyspnea, and overall failure to thrive prompted her family to pursue hospice care. DISCUSSION: PH can cause herniation of abdominal contents into the thorax causing significant morbidity with median age of presentation between 65-75 years (1). With large phrenoesophageal membrane defects, organs including stomach, spleen, and small intestine can herniate. Diagnosis is made by barium swallow, endoscopy or CT (2). Treatment for advanced, symptomatic disease refractory to medical treatment is surgical. Given the need to insufflate the peritoneal cavity, laparoscopic repair can occasionally lead to insignificant surgical emphysema and pneumomediastinum or small pneumothorax (3). However, this can infrequently cause hemodynamic instability, and to our knowledge, there is no literature reporting an inflated visceral peritoneal sac protruding into the thorax causing tension physiology as in our patient. Diagnosis is based on clinical findings of shock and imaging showing mediastinal structure compression and shift. Treatment is based on decompression and, in patients stable for surgery, resection of the hernia sac. CONCLUSIONS: Visceral peritoneal sac herniation and insufflation with air-fluid level causing tension physiology is a rare phenomenon post-PE repair that can cause significant hemodynamic instability and morbidity. Clinical exam and radiographic imaging followed by quick decompression play a key role in swift recognition and urgent treatment. REFERENCE #1: Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg. 2015;2:13. REFERENCE #2: Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349(oct23 1):g6154-g6154. REFERENCE #3: Singhal T, Balakrishnan S, Hussain A, Grandy-Smith S, Paix A, El-Hasani S. Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective. Ann Surg Innov Res. 2009;3:1. DISCLOSURES: No relevant relationships by Pavan Bhat, source=Web Response no disclosure on file for Robert Cole; No relevant relationships by Theodore Plush, source=Web Response

Incidence, Management, and Outcomes of Patients With COVID-19 and Pneumothorax

BackgroundOur objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). MethodsA single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. ResultsFrom March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). ConclusionsThe incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.

Pneumothorax in patients with respiratory failure in ICU.

Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.

Electrocardiographic manifestations in a large right-sided pneumothorax

BackgroundPneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated.Case presentationA 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98/68 mmHg, tachycardia of 100 beats/min, tachypnea of 28 breaths/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4–6, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient’s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46 × 49 mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy.ConclusionsHerein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea.

Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study.

The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12). Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Pneumothorax in COVID-19 Acute Respiratory Distress Syndrome: Case Series.

ObjectiveThe study aims to describe the clinical characteristics and outcomes of patients with COVID-19 related acute respiratory distress syndrome (ARDS) who developed pneumothorax.Design and settingA retrospective chart review was performed of the electronic medical record. Patients were included if they were identified as having confirmed COVID-19 as well as pneumothorax from March 16, 2020 to May 31, 2020. Patients' demographic and clinical characteristics, mechanical ventilator parameters, lung compliance measurements and outcomes during hospitalization were collected. This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State.PatientsA total of 75 patients were identified who were predominantly male (73.3%) with an average age of 62.8 years. Thirty (40%) were Hispanic, 20 (26.7%) were White, 16 (21.3%) were Asian, and nine (12%) were Black. Common comorbid conditions were hypertension (52%), diabetes mellitus (26.7%), hyperlipidemia (32.0%), and chronic pulmonary disease (8, 10.7%).Measurements and main resultsMost of the patients were diagnosed with pneumothorax while on mechanical ventilation (92%) despite overall adherence with lung-protective ventilation strategies. Average tidal volume was 6.66 mL/kg) of ideal body weight. The average positive end-expiratory pressure (PEEP) was 10.83 (cm) H2O. Lung compliance was poor, with average peak and plateau pressures of 41.9 cm H2O and 35.2 cm H2O, respectively. Inpatient mortality was high in these patients (76%). Conservative management with initial observation had a success rate (73.3%) with similar mortality and shorter length of stay (LOS) on average. Significant factors in the conservatively managed group included lack of tension physiology, the smaller size of pneumothorax, lack of underlying diabetes, presence of pneumomediastinum, and not being on mechanical ventilation during diagnosis.ConclusionDespite overall adherence to best practice ventilator management in ARDS, we observed a large number of pneumothoraces during the COVID-19 pandemic. Conservative management may be appropriate if there are no clinical signs or symptoms of tension physiology and pneumothorax size is small.

Tension pneumoperitoneum following upper endoscopy

Perforation of the digestive tract is a rare complication of endoscopy. Massive accumulation of air within the peritoneum resulting in the abdominal compartment syndrome is much less common with <20 cases reported. In this report we present a case of jejunal perforation during an upper gastrointestinal endoscopy that resulted in tension physiology with mesenteric ischemia, severe acidosis, renal failure, coagulopathy and massive gastrointestinal hemorrhage. The patient had a sudden onset of shock as soon as her abdomen was decompressed, indicating that she possibly developed a reperfusion injury. She did not respond to resuscitative efforts and ultimately died.

Successful treatment of post-infectious pneumatocele via percutaneous drainage in a premature infant

Abstract Pneumatoceles are air-filled cysts within the lung parenchyma that can have a connection to the bronchial tree. These are often seen following severe lung infections mainly with Staphylococcus aureus (S. aureus). Currently there is no consensus on management of these lesions. We present the case of a premature 28 weeks gestational age male infant, born at an outside hospital, requiring intubation shortly after birth for respiratory distress, who during the first week of life developed a S. aureus pneumonia. He was treated with a three-week course of Nafcillin but on day of life (DOL) 13, chest radiographs (CXR) demonstrated the presence of a right upper lobe pneumatocele. Despite treatment of the pneumonia, the pneumatocele persisted. It steadily enlarged and progressed to an acute tension physiology presentation. Despite supportive care with maximal ventilatory support, the clinical condition deteriorated which led to a decision for surgical intervention. Because of the extremely high mortality risk associated with a formal lung resection in this premature infant, a percutaneous drain was placed at the bedside on DOL76. The drain remained in place until DOL106 when complete resolution of the pneumatocele prompted removal of the tube. During the prolonged course that the drain was in place, there were intermittent air leaks as well as pneumatocele expansion episodes that prompted intermittent suction. Based on our limited experience, single percutaneous chest tube drainage is a viable option for treatment of large post-infectious pneumatocele in preterm infants.

FROM A SIMPLE COLD SORE TO SEVERE CYSTIC LUNG DISEASE

SESSION TITLE: Chest Infections 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Necrotizing fasciitis, septic embolic, and tension pneumothorax are all individually a cause of significant morbidity and mortality. When combined, they pose a significant treatment dilemma, as options in critically ill patients are limited. Here we present a case of a cold sore leading to multiple pneumothoraces from septic emboli causing severe cystic lung disease. CASE PRESENTATION: A 57-year-old healthy male presented with fever, facial swelling, and dyspnea. He reported a cold sore lesion that rapidly progressed into right facial and neck swelling. A CT of the head and neck showed extensive edema involving the facial plane extending to the parapharyngeal space suggestive of necrotizing fasciitis. He underwent emergent debridement in the operating room, blood and wound cultures grew methicillin sensitive S.aureus. His course progressed to hypoxic respiratory failure complicated by a spontaneous tension pneumothorax (PTX) requiring chest tube placement. Despite lung protective ventilation he developed diffuse cystic lung lesions and moderate bilateral loculated PTXs with tension physiology that led to cardiac arrest. He was ultimately revived, however required seven chest tubes, each with persistent air leaks. Pleurodesis or surgical/endoscopic procedures were not attempted, as he was too unstable. During the course of 2 months, he was maintained on mechanical ventilation via tracheostomy, IV antibiotics, and dialysis. As he gradually improved he was weaned from mechanical ventilation, allowing his air leaks to resolve and his chest tubes removed. DISCUSSION: A tension pneumothorax secondary to septic emboli is a rare yet possibly fatal disease. Here we present a case of necrotizing fasciitis from a simple cold sore progressing to multiple pulmonary septic emboli. This led to severe cystic lung disease from the multiple loculated and tension pneumothoraces. Multiple pneumothoraces with persistent air leaks posed a significant challenge to management, where preferred treatment is surgical repair. These air leaks make ventilation and oxygenation incredibly difficult, leading the inability to wean from the ventilator. Such critically ill patients are too high risk for surgical intervention, however this case demonstrates where conservative management led to the patients ultimate recovery. Endobronchial valves may still be promising in such dilemmas shown by recent observational studies. However there are no controlled studies to compare these new approaches, and therefore the clinician’s best judgment must be used. CONCLUSIONS: Diffuse cystic lung diseases (DCLD) present from varying pathophysiologic mechanisms. DCLD do not have a homogenous distribution, but they do share pneumothoraces. Management with positive pressure ventilation was cumbersome in this patient when the risk for recurrence remains high past this hospitalization. Reference #1: Okabe M, Kasai K, Yokoo T. Pneumothorax Secondary to Septic Pulmonary Emboli in a Long-term Hemodialysis Patient with Psoas Abscess. Internal Medicine. 2017;56(23):3243-3247. https://doi.org/10.2169/internalmedicine.9050-17. Reference #2: Cystic Lung Diseases: Algorithmic Approach. Raoof S., Bondalapati P., Vydyula R., Ryu J.H., Gupta N., Raoof S., Galvin J., (…), Naidich D. (2016) Chest, 150 (4) , pp. 945-965. DISCLOSURES: No relevant relationships by Hassan Al Khalisy, source=Web Response no disclosure on file for Ioana Amzuta; No relevant relationships by Marsha Antoine, source=Web Response No relevant relationships by Ritu Modi, source=Web Response No relevant relationships by Bashar Sharma, source=Web Response