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Allergy and Airway

Chest. 2013;144(4_MeetingAbstracts):1A. doi:10.1378/chest.1675132

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchial atresia (BA) is a rare congenital abnormality of the tracheobronchial tree. We report a case of a 47-year old female incidentally found with this condition.

CASE PRESENTATION: The patient, a non-smoker with a history of asthma, presented with difficulty breathing. She was on inhaled bronchodilators for her asthma which was not well-controlled. No history of fevers, chronic cough, hemoptysis, weight loss or environmental or occupational exposures was present. Examination was unremarkable. Lungs were clear to auscultation. Cardiac examination was normal. Chest x-ray revealed two circumscribed masses in her right upper lobe (Image 1). A Computerized Tomogram(CT)-guided needle biopsy was planned. However, on CT chest, the masses appeared to have a fluid attenuation and were peripherally distributed with localized hyperlucency distal to the mass (Image 2). The mass-like lesions represented the obstructed bronchus, dilated due to mucus impaction, with localized area of hyperinflation manifest as increased lucency distal to the lesion.Bronchial atresia (BA) was diagnosed based upon these characteristic CT findings. The patient was treated with bronchodilators and inhaled corticosteroids, with improvement in her asthma symptoms. On follow-up 6 months later, the patient is doing well without any sequelae.

DISCUSSION: BA, a rare congenital tracheobronchial anomaly, occurs predominantly in males. A vascular insult during embryogenesis has been implicated in its causation. It is characterized by a focal narrowing of a sub-segmental, segmental or lobar bronchus, associated with mucocele formation due to mucus impaction, and hyperinflation of the distal segment of lung. The alveoli supplied by the obstructed bronchi are ventilated via collateral airways, resulting in air-trapping and localized hyperinflation.Most patients are asymptomatic with about 30% experiencing recurrent respiratory infections, cough, dyspnea or haemoptysis. At present, BA is usually diagnosed by CT. Bronchoscopy may be non-diagnostic but maybe required in cases where similar findings on CT can be found, such as lung cancer or bronchial adenoma.Tissue biopsy is not essential for diagnosis, if characteristic CT features are present. Management is conservative unless there is a superimposed infection of the mucocele. Surgical excision is generally reserved for patients with recurrent infections.

CONCLUSIONS: BA is a rare congenital tracheo-bronchial malformation. If CT chest shows characteristic findings, tissue biopsy is not required for diagnosis. Surgery is required when complications such as encroachment of normal lung tissue or recurrent infections occur.

Reference #1: Mori M et al: Bronchial Atresia: Report of a Case and Review of the Literature.Surgery Today1993. 23:449-454.

Reference #2: Ramsey BH et al: Mycocele, congenital bronchiectasis and bronchogenic cyst. J Thorac Surg 1953, 26:21-29.

Reference #3: Zylak CJ et al: Developmental Lung Anomalies. Radiographics 2002; 22:S25-43.

DISCLOSURE: The following authors have nothing to disclose: Thomas Waring, Danae Delivanis, Anat Bergner, E. Kaloudis, D. Datta

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Topics: lung mass
Chest. 2013;144(4_MeetingAbstracts):2A. doi:10.1378/chest.1664441

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemoptysis is relatively common with most cases arising from either infection or malignancy; however, hemoptysis from lithoptysis is quite rare. We present a case of hemoptysis with concurrent lithoptysis as the initial presentation of a prior granulomatous pulmonary process.

CASE PRESENTATION: A 72-year-old former Ecuadorian farmer presents after coughing up three to four tablespoons of bright red blood for three days. His past medical history is significant for cholelithiasis with a complicated cholecystectomy. He has no known history of tuberculosis or exposures. On exam his vital signs are normal with an oxygen saturation of 98% on room air. His lungs are clear and there is a surgical scar in the right upper quadrant of his abdomen. The rest of his exam is normal. On hospital day two he reported coughing up “some stones” (figure 1) that he presumed originated from his gallbladder. Bronchoscopy revealed multiple broncholiths (figure 2) corresponding to areas of calcification seen on a chest CT. His sputum smear and respiratory cultures were negative for acid-fast bacilli, bacterial, and fungal organisms. A serum QuantiFERON-TB Gold test was reactive and serum antibodies for Histoplasmosis and Cryptococcus were negative. Histologic examination of an endobronchial biopsy revealed chronic inflammation with no stainable fungal elements.

DISCUSSION: Broncholiths arise from the calcification of peribronchial lymph nodes that distort or obstruct the lumen of the airways and lithoptysis is the result of expectorated broncholiths that have eroded into the airways; most commonly as the result of a chronic granulomatous lymphadenitis. Worldwide Mycobacterium tuberculosis is responsible for most cases of broncholithiasis, but in North America Histoplasmosis capsulatum is more common.(1) Other causes include cryptococcosis, aspergillosis, coccidioidomycosis, actinomycosis, and silicosis. Common complications include hemoptysis, chronic cough, bronchial obstruction, recurrent pneumonia, and bronchoesophageal fistulas.(2) In symptomatic patients, without massive hemoptysis, initial removal can be attempted via bronchoscopy. However, surgical management is reserved for symptomatic patients with bronchoesophageal fistula, massive hemoptysis, or failed bronchoscopic management. Asymptomatic patients can be managed with observation alone.(3)

CONCLUSIONS: This case highlights an unusual and late presentation of a patient with a prior granulomatous pulmonary process, presumably from past tuberculosis exposure.

Reference #1: Antao VCS, Pinheiro GA, Jansen JM. Broncholithiasis and lithoptysis associated with silicosis. Eur Respir J 2002;20:1057-1059.

Reference #2: Seo JB, Song KS, et al. Broncholithiasis: Review of the Causes with Radiologic-Pathologic Correlation. RadioGraphics 2002;22:S199-S213.

Reference #3: Cerfloio RJ, Bryant AS, Maniscalco L. Rigid bronchoscopy and surgical resection for broncholithiasis and calcified mediastinal lymph nodes. J Thorac Cardiovasc Surg 2008;136:186-190.

DISCLOSURE: The following authors have nothing to disclose: David Weir, Terence McGarry

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Topics: hemoptysis
Chest. 2013;144(4_MeetingAbstracts):3A. doi:10.1378/chest.1702047

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Hamartomas are the most common non-malignant lung tumors, but their endobronchial occurance is rare. They are often described as solitary “coin lesion” on chest imaging. We report the oldest case known in literature with a new diagnosis of a pair of endobronchial hamartoma in the same location.

CASE PRESENTATION: A 91 y old woman presented with altered mentation, dyspnea and hypoxia, eventually requiring intubation and admission to ICU. Notably, she had recurrent admissions for pneumonia over the last year. On the day of presentation, nursing home records documented a witnessed aspiration. After four days of antibiotics, fever and leukocytosis subsided but left lower lobe density persisted despite chest percussion and aggressive suctioning. CT chest showed collapse of the posterior segment of left lower lobe, with obliteration of the airway. No definite mass was reported. Subsequent flexible bronchoscopy revealed patent lumen till the bifurcation of left posterior and lateral basal segment, where the mucosa appeared inflamed. Inability to pass bronchoscope distally prompted use of the cytobrush, which hit a firm obstruction. Consequent use of forceps to remove or biopsy the obstructing lesion pulled two smooth whitish pedunculated lesions in the proximal left lower lobe bronchus. Multiple biopsies were taken, but removal of the lesion not attempted due to its indeterminate origin or etiology. Biopsies revealed fragments of inflamed bronchial tissue, pure cartilage and fibrinous material, suggestive of endobronchial chondroid hamartoma. Removal of the hamartoma was discussed with family, but not pursued due to patient’s underlying dementia and minimal baseline functionality.

DISCUSSION: Pulmonary hamartomas range in incidence from 0.025% to 0.34%; only 1.4% are endobronchial. To date, our patient is the oldest reported case, reiterating its slow-growing and benign nature. Hamartomas are almost always solitary, but we found two adjacent well-defined ones, which is very rare. The two most common histologic patterns described were that of chondroid and lipoid hamartoma (37.2% and 30.2% of cases, respectively). Endobronchial hamartomas present with recurrent pneumonia, hemoptysis, cough, dyspnea and wheezing in over 80% of the cases. Procedures like rigid bronchoscopy with/without laser, fiberoptic bronchoscopy with snare/forceps removal and surgery have yielded permanent cures with rare recurrence.

CONCLUSIONS: 1. Recurrent pneumonia with persistent segmental collapse should prompt early bronchoscopic evaluation. 2. Endobronchial hamartomas are frequently symptomatic, but can be definitively cured, avoiding complications and excess cost to healthcare.

Reference #1: Gjevre et al. Pulmonary hamartomas. Mayo Clin Proc 1996; 71:14-20

Reference #2: Cosío et al. Endobronchial hamartoma. Chest. 2002 Jul;122(1):202-5.

DISCLOSURE: The following authors have nothing to disclose: Abhishek Kumar, Arjun Mohan, Prerna Kumar, Philippe Jaoude

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Topics: pneumonia
Chest. 2013;144(4_MeetingAbstracts):4A. doi:10.1378/chest.1704003

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Immigration and cultural exchanges bring global diversity to diseases we see in our practice. We present here the story of a young Burmese man with chronic cough causing multiple physicians and emergency room (ER) visits over 1.5 years, without a diagnosis or improvement.

CASE PRESENTATION: A 23 y old Burmese non-smoking man was referred with chronic cough for ~1.5 yrs. History included treated tuberculosis 5 yrs. ago. Expectoration had occasional blood streaks, not associated with fever, chills, chest pain, weight loss or appetite loss. In last 18 months, he visited many physicians and ERs, including a nearby university hospital for this cough. Repeatedly, he had normal chest x-rays, and was discharged with cough suppressants and antibiotics, without relief. He was eventually referred to a pulmonologist. A CT chest done after chest x-ray was again unrevealing showed a calcified granuloma in right lower lobe, and a calcified endobronchial lesion in bronchus intermedius. Flexible bronchoscopy revealed near-complete obliteration of bronchus intermedius by a zebra-skin patterned lesion surrounded by well-formed bronchial tissue. Direct pressure by tip of bronchoscope moved it distally, partly freeing it from the surrounding tissue. After failing with forceps, snare and fogarthy catheter, we extracted a 1.5 cm sharp stone-like object using the basket catheter. A closer inspection identified the object as betel-nut (Areca catechu), a mouth-freshener frequently chewed in South Asia. Patient’s wife later confirmed his betel-nut addiction. Cough finally resolved after bronchoscopy. Biopsy of surrounding tissue revealed non-malignant squamous metaplasia with fibrin, and inflamed granulation tissue.

DISCUSSION: Areca catechu is a WHO group-1 carcinogen, known to cause squamous cell carcinoma. Worldwide, it is the fourth most common addictive substance, and is culturally prevalent in South Asia. Areca extract (containing Arecoline) causes airway remodeling with smooth muscle hyperplasia and fibrinous subepithelial deposits, and worsens asthma. Having developed squamous metaplasia, this patient may soon have progressed to squamous carcinoma at the endobronchial site of contact. Foreign body aspiration is more common in children and elderly, unlike our young patient. A prospective study by Magsi et al. in rural Pakistan reported betel nut as the most common airway foreign body removed. This habit is unheard of in USA, and hence, was never on our differential. This case highlights a cultural aspect of medicine uncommon in our practice.

CONCLUSIONS: 1. Cultural habits should be paid attention to in history-taking of immigrant population. 2. Chest x-ray is often unrevealing for foreign body aspirations.

Reference #1: Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore. 2004 Jul;33(4 Suppl):31-6.

Reference #2: Magsi et al. Experience of foreign bodies in aero-digestive tract at tertiary care hospital Sukkur, Pakista. RMJ. 2011; 36(4): 277-280.

DISCLOSURE: The following authors have nothing to disclose: Abhishek Kumar, Arjun Mohan, Prerna Kumar, Kurt VonFricken

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Chest. 2013;144(4_MeetingAbstracts):5A. doi:10.1378/chest.1704038

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Measurement of endotracheal cuff pressures has been recommended to avoid overinflation, which can contribute to tracheal ischemia and tracheomalacia. We report the case of an intubated patient who suffered tracheal wall dehiscence after prolonged cuff overinflation. Retrospective review of plain chest films revealed a trend of increasing cuff diameter that could potentially highlight patients at risk for tracheal damage.

CASE PRESENTATION: A 46 year old man with morbid obesity, diabetes, and hypertension was admitted with hypercarbic respiratory failure. The patient was intubated and failed daily weaning trials. On his 15th day of intubation, blood was noted in the endotracheal tube. This quickly progressed to massive hemoptysis. Bronchoscopy revealed a posterior tracheal tear with active bleeding. Cuff pressure obtained via manometry was 70 cmH2O (recommended range: 20-40 cmH2O) (1) despite a leak around the cuff. A tracheostomy revealed severe tracheomalacia with a dehiscent posterior tracheal wall. A chest film prior to tracheostomy revealed gross dilatation of the endotracheal balloon cuff. Films dating from admission revealed a gradual increase in dilatation. The initial width of the trachea at the cuff was 1.55 cm and increased to 3.86 cm on the day prior to tracheostomy. This trend was preserved after adjusting for roentographic technique by indexing the tracheal width to the known diameter of the endotracheal tube.

DISCUSSION: Overinflation of the endotracheal cuff beyond 20-40 cm H2O causes ischemia of the tracheal vasculature (2). This, in turn, can lead to tracheomalacia, tracheal stenosis, tracheal dehiscence and perforation. Previous studies have shown poor correlation between radiographic findings and cuff pressure (3). Differences in film technique can hinder objective interpretation. While cuff diameter varies, the diameter of the endotracheal tube is fixed. By using this known diameter as a correction factor, measurement of the trachea at the cuff may offer an early sign of tracheomalacia due to cuff overinflation.

CONCLUSIONS: Routine measurement of endotracheal cuff pressures has not yet been implemented in many ICUs. While direct manometry remains the only reliable method of ensuring therapeutic cuff pressures, trending of chest films in the intubated patient may prove a useful adjunct for identifying at-risk patients before they manifest potentially catastrophic complications.

Reference #1: Stewart, S., et al. “A Comparison of Endotracheal Tube Cuff Pressures Using Estimation Techniques and Direct Intracuff Measurement.” AANA Journal. December 2003. 71(6): 443-7.

Reference #2: Seegobin, R. and van Hasselt, G. “Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs.” Br Med J. 1984. 288(6422): 965-8.

Reference #3: Valentino, J., et al. “Utility of portable chest radiographs as a predictor of endotracheal tube cuff pressure.” Otolaryngology - Head and Neck Surgery. 1999. 120(1): 51-6.

DISCLOSURE: The following authors have nothing to disclose: Mark Valdez, Vincent Cunanan, Luke White

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Chest. 2013;144(4_MeetingAbstracts):6A. doi:10.1378/chest.1705210

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheal rupture is a rare but life-threatening complication commonly seen after blunt trauma to the chest, penetrating gunshot and iatrogenic injury. Orotracheal intubation is reported to be the most common cause of iatrogenic tracheal injury. Early signs of intubation related tracheal rupture, such as respiratory distress, subcutaneous emphysema or death are usually present after the procedure.

CASE PRESENTATION: : 56 year-old woman developed acute respiratory failure due to COPD exacerbation. She was intubated after several attempts at the emergency department. A portable CXR post intubation revealed severe subcutaneous emphysema; a chest CT confirmed a tracheal rupture. A Bronchoscopy performed 12 hours after intubation showed a posterior tracheal rupture of 3-4 cm long located 1 cm above the carina, the membranous trachea lesion opened and closed on respiratory cycle. The location and length of the lesion and the patient being asymptomatic favored a conservative treatment with broad-spectrum antibiotics, fasting and post re-evaluation of the airway. The patient made a full and uncomplicated recovery

DISCUSSION: Tracheal rupture is a rare but potentially catastrophic event. When the injury is related to an intubation procedure, likely occurs in an emergency situation. The multiple factors leading to this injury are several attempts, inexperienced physicians, inappropriate use of styles, cuff over inflation, malposition of the tube and improper tube size. Two therapeutic approaches are proposed in the literature, surgical vs. medical management. Conservative management was chosen based on to the length and location of the laceration. It’s recommended to add empiric antibiotics, nothing by month for several days and offer analgesia if needed.

CONCLUSIONS: This case report presents an iatrogenic post-intubation tracheal rupture treated conservatively. It also illustrates the effectiveness of the non-surgical therapeutic strategy.

Reference #1: Carbognani P, Bobbio A, Cattelani L, Internullo E, Caporale D, Rusca M: Management of postintubation membranous tracheal rupture. Ann Thorac Surg 2004, 77:406-409.

DISCLOSURE: The following authors have nothing to disclose: Ivan Romero-Legro, Bassam Yaghmour, Amado Freire, Luis Murillo

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Chest. 2013;144(4_MeetingAbstracts):7A. doi:10.1378/chest.1699520

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchoscopic cryoextraction using a cryoprobe is a lesser studied therapeutic modality which can be used to remove foreign bodies, especially those containing sufficient water or freezable liquid from the lower airways. Acute symptomatic airway obstruction due to blood clots can develop as complication from various pulmonary procedures.

CASE PRESENTATION: A 54 years old male with history of renal transplant, on chronic immunosuppressant therapy was admitted to the intensive care unit with right lower lobe pneumonia (Figure 1 Panel A ) requiring endotracheal intubation due to hypoxic respiratory failure. Due to history of chronic immunosuppressive therapy a bronchoalveolar lavage (BAL) was attempted for targeted antimicrobial therapy. Bronchoscopic exam of the airways showed friable endobronchial mucosa with thick purulent secretions. Unfortunately a massive endobronchial bleed due to iatrogenic mucosal tear complicated the procedure. Patient became extremely hypoxic despite 100% FIO2. Urgent chest radiograph showed worse right lower lobe infiltrates and atelectasis (Figure 1 Panel B). A repeat bronchoscopic exam showed massive blood clot occluding the right main stem bronchus. Removal of blood clot was felt to be necessary to improve oxygenation; this was not achievable with bronchoscopic suction. A cryoprobe was inserted through the bronchoscope into the airways and was applied to the clot and frozen. Clot got firmly attached to the probe and was successfully pulled out in large piece (Figure 2). This resulted in immediate improvement in patient’s oxygenation.

DISCUSSION: Bronchial mucosal damage from infections, tumors, suction catheter manipulation during flexible bronchoscopy can result in endobronchial bleeding. On occasions this can lead to large airway clot formation causing acute airway obstruction and ultimately resulting in significant hypoxia. Different instruments used in foreign body removal (grasping forceps, balloon catheters, baskets, snares, magnets and so on) are usually ineffective due to friable structure of the clot. Suctioning of the blood clot with flexible bronchoscope is not always successful and could pose a risk of rebleeding. Cryoextraction allows freezing of the blood clots leading to their adhesion to the probe and thus successful removal.

CONCLUSIONS: Cryoextraction is a safe and effective modality in the removal of large endobronchial blood clots causing symptomatic obstruction. In addition to the immediate effect and it has a short learning curve, the procedure has few complications and is cost-effective.

Reference #1: 1.Weerdt S, Noppen M, Remels L, et al. Successful removal of a massive endobronchial clot by means of cryotherapy. Journal of Bronchology. 2005; 12:23-24.

Reference #2: 2.Franke KJ, Nilius G, Rühle KH. Use of cryoextraction in different types of airway obstruction. Pneumologie. 2010; 64:387-9.

DISCLOSURE: The following authors have nothing to disclose: Himanshu Bhardwaj, Bhaskar Bhardwaj, Ahmed Awab, HOussein Youness

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Chest. 2013;144(4_MeetingAbstracts):8A. doi:10.1378/chest.1701279

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Chronic cough is a common complaint in pulmonary medicine. We present an uncommon cause of chronic cough in an otherwise healthy adult.

CASE PRESENTATION: An 86-year old Caucasian male with history of hypothyroidism and hyperlipidemia presented with cough for one year. His cough was initially non-productive, mostly positional and occurs when he lies on his right side and also when he stands up. He was a lifelong non-smoker and denied history of asthma, gastroesophageal reflux symptoms, post-nasal drip or angiotensin converting enzyme inhibitor use. He denied weight loss or night sweats. His cough eventually became progressive and productive of yellowish sputum and he was noted to have fevers. These symptoms persisted despite courses of Azithromycin and Levofloxacin for presumed bronchitis. Physical examination revealed an elderly gentleman, speaking in full sentences, not ill appearing, and not in respiratory distress. He was febrile to 101F with oxygen saturation of 96% on room air. Lung examination revealed symmetric chest expansion with right basilar dullness to percussion, rhonchi, egophony, and increased tactile fremitus. Review of his chest x-ray 10 months prior to presentation revealed mild right basilar discoid atelectasis. Chest x-ray on presentation revealed right basilar discoid atelectasis with lateral view showing increased opacification of the right lower lobe. Subsequent chest computed tomography (CT) revealed right lower lobe consolidation and atelectasis with an endobronchial object seen proximal to the takeoff of the right lower lobe bronchi (Figure 1). Fiberoptic bronchoscopy revealed an endobronchial obstruction at the takeoff of the right lower lobe bronchi by a globular mucus-coated piece of organic material (Figure 2). Forceps and cryotherapy were employed to remove the object, and copious mucopurulent secretions were seen distally. Pathological analysis of the foreign body was consistent with vegetable matter. After the foreign body was removed, the patient was treated with a course of Augmentin with complete resolution of his cough and fever.

DISCUSSION: Foreign body aspiration in adults can be subtle and remain undetected for years if the foreign body is small enough to lodge in the lobar or segmental bronchus. Cough is the most common symptom. Radiologic findings can include atelectasis, air trapping, and pneumonia. Treatment is removal of the foreign body. Most frequent procedure is fiberoptic bronchoscopy.

CONCLUSIONS: One needs to have a high index of suspicion to diagnose aspiration if cough does not resolve with the usual empiric therapy, especially if there is pneumonia that does not respond to standard treatment.

Reference #1: Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies. Presentation and management in children and adults. Chest. 1999;115:1357-62.

DISCLOSURE: The following authors have nothing to disclose: Jeffrey Albores, Joanne Bando

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Chest. 2013;144(4_MeetingAbstracts):9A. doi:10.1378/chest.1704904

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Congenital bronchial atresia is a rare entity, mostly discovered as an incidental finding on chest imaging. It usually involves the atresia of a segmental or subsegmental bronchus. It is one of the differential diagnoses of finger-in-glove sign where mucus is impaction occurs in the lung and surrounded by hyperlucent lung

CASE PRESENTATION: A 50-year-old female presented with chronic cough and an abnormal chest radiograph. She usually had worsening of her cough during spring and summer months, and had used over the counter cough suppressants. She denied any shortness of breath, wheezing, hemoptysis, or chest pain. She had 30 pack year smoking history. she was not in any respiratory distress with Respiratory rate of 12/min and resting saturation of 99%. The breath sounds were decreased in the right upper thorax with normal vesicular breaths sounds without any adventitious sounds elsewhere. A chest radiograph showed an ill-defined, elongated mass in the right middle lung zone. CT scan showed irregular tubular structure with mucus impaction, presenting like finger in glove appearance in the right upper lobe (Fig 1). The apical segment of the right upper lobe could not be traced. Bronchoscopy (Fig 2) showed only two segmental division of the right upper lobe and also a remnant of superior segment of the lower lobe

DISCUSSION: Bronchial atresia is hypothesized to develop as a result of intrauterine ischemia after the 16th gestational week. The chest x ray shows tubular or nodular area of increased opacity that extends from the hila. CT scan more sensitive and shows triad of focal interruption of a bronchus, bronchocele, and associated hyperinflation of the obstructed pulmonary segment

CONCLUSIONS: Bronchial atreisa is one of the causes of focal hyperlucnet lung along with finger glove appearence on radiograms. Most pateints with bronchial atresia are asymptamatic and require no treatment. CT scan and bronchoscopy helps to rule out other causes like cystic fibrosis, ABPA and bronchiectasis .

Reference #1: Congenital bronchial atresia (CBA). A critical review of CBA as a disease entity and presentation of a case series. Pedicellj G and et all. Radiol Medi: 110(5-6):544-53

Reference #2: Congenital bronchial atresia: diagnosis and treatment. Wang Y and et all . Int j Med Sci: 207-12:2012;9(3).

DISCLOSURE: The following authors have nothing to disclose: Penchala Mittadodla, Mohan Rudrappa, Mohammad Siddiqui

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Chest. 2013;144(4_MeetingAbstracts):10A. doi:10.1378/chest.1704867

SESSION TITLE: Airway Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Ehlers-Danlos Syndrome (EDS) type IV (vascular type) is a rare, hereditary disease caused by mutations within the gene for type III procollagen (COL3A1). Afflicted individuals commonly suffer from large vessel bleeding and premature death from arterial, bowel, and/or uterine rupture (1). Less frequently, but equally significant, are pulmonary complications including tracheobronchomalacia (TBM). To our knowledge, we describe the first case of a patient with EDS type IV with severe TBM who underwent silicone stent placement and eventual tracheobronchoplasty resulting in successful central airway stabilization and resolution of respiratory symptoms.

CASE PRESENTATION: A 44 year old female with a complicated history of EDS type IV, presented with recurrent respiratory distress including audible stridor. CT imaging revealed a decrease in caliber of the central airways of greater than 50% on the expiratory phase which is diagnostic of TBM. Despite steroids, antibiotics, heliox and non-invasive positive pressure ventilation, she eventually required intubation. She was transferred to our institution and underwent flexible bronchoscopy which confirmed severe TBM. A dynamic Y stent was placed in the tracheobronchial tree; she was extubated in the OR and discharged home the next day. Subsequently, she required two hospitalizations for dyspnea, acute stridor due to transient stent migration and difficulty clearing sections. These complications were managed bronchoscopically and with a strict pulmonary toilet regimen. Six weeks following stent placement she showed significant symptomatic improvement and within 4 months she underwent successful tracheobronchoplasty at another institution.

DISCUSSION: Serious and potentially fatal pulmonary complications such as airway obstruction from TBM may occur in subjects with EDS type IV. Treatment options for TBM remain largely supportive. When TBM is severe, airway stabilization with silicone stents can improve respiratory symptoms (2) and tracheobronchoplasty can then be pursued (3).

CONCLUSIONS: To our knowledge, this is the first case report describing the use of silicone stenting for severe TBM associated with EDS that successfully provided airway stabilization and symptomatic relief until a tracheobronchoplasty was performed. The diagnosis of TBM should be considered in patients presenting with recurrent respiratory failure including patients with EDS.

Reference #1: Pepin M, Schwarze U, Superti-Furga A, et al. Clinical and Genetic Features of Ehlers-Danlos Syndrome Type IV, The Vascular Type. NEJM 2000; 342:673-680

Reference #2: Ernst A, Majid A, Feller-Kopman D, et al. Airway Stabilization With Silicone Stents for Treating Adult Tracheobronchomalacia. CHEST 2007; 132:609-613

Reference #3: Majid A, Guerrero J, Gangadharan S, et al. Tracheobronchoplasty for Severe Tracheobronchomalacia: A Prospective Outcome Analysis. CHEST 2008; 134:801-807

DISCLOSURE: The following authors have nothing to disclose: Alichia Paton, Preethi Rajan, Stephen Pastores, Neil Halpern, Mohit Chawla

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Chest. 2013;144(4_MeetingAbstracts):11A. doi:10.1378/chest.1705270

SESSION TITLE: Airway Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Endoscopic management of tracheal stenosis has been shown to be successful. However, the utility of this approach in complete obstruction is unknown. We present a case of complete tracheal stenosis successfully treated using flexible bronchoscopy (FB) and retrograde transillumination.

CASE PRESENTATION: A 40-year-old male, with a history of prolonged mechanical ventilation and tracheostomy following a motorcycle accident, presented for treatment of complete suprastomal tracheal obstruction after previously refusing surgical resection-anastomosis. Physical examination was unremarkable except for a tracheostomy tube. FB revealed 100% occlusion of the trachea 3-cm below the vocal cords. A second bronchoscope was inserted through the tracheostomy stoma and advanced in a retrograde fashion towards the vocal cords. With the lamp turned off on the first bronchoscope, distal tracheal lumen was identified with transillumination. A 19G Wang needle was first inserted from above to create a small opening. Argon plasma coagulation and balloon dilation were subsequently used to enlarge the orifice. Post-procedure, the tracheal lumen was 50% of normal size. Repeat FB four weeks later showed granulation tissue with 90% stenosis; cryotherapy and balloon dilation were performed. Post-procedure, the lumen size was more than 50% of normal, and he was able to speak with occluding the tracheostomy. He has since required several follow-up bronchoscopic interventions. He continues to speak with the aid of a speaking valve on a fenestrated tracheostomy tube after six months and has had subjective improvement in his overall quality of life.

DISCUSSION: Successful treatment of total tracheal obstruction has previously been described using rigid bronchoscopy, retrograde transillumination, and T-tube or stent placement. Differing from this approach, we opted to use dual FB. We were able to successfully achieve airway patency without a stent placement and he regained his ability to speak utilizing this approach with a combination of interventional modalities. We feel that retrograde transillumination contributed to the success of this procedure and provided an added measure of safety by identifying and allowing direction of intervention towards the tracheal lumen. Retrograde transillumination will be a useful adjunct in the bronchoscopic management of complete tracheal stenosis. We describe the first case of its use in conjunction with flexible bronchoscopy.

CONCLUSIONS: This case illustrates the potential for FB in the treatment of complete tracheal stenosis. Retrograde transillumination allows for a safe endobronchial approach.

Reference #1: Vandemoortele, T et al. Endobronchial Treatment of Complete Tracheal Stenosis: Report of 3 Cases and Description of an Innovative Technique. Ann Thorac Surg. 2013; 95: 351-354

DISCLOSURE: The following authors have nothing to disclose: Douglas Closser, Shaheen Islam

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Chest. 2013;144(4_MeetingAbstracts):12A. doi:10.1378/chest.1698941

SESSION TITLE: Airway Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Neurogenic tumors arising from the larynx are extremely rare. Sucharek reported the first case of laryngeal neurofibroma in 1925. We describe an adult patient with laryngeal neurofibroma who presented with shortness of breath and cough

CASE PRESENTATION: A 35-year-old Caucasian male presented to pulmonary clinic for evaluation of intermittent shortness of breath and cough, which he had for 8 months. Prior to his presentation he was treated with multiple doses of antibiotics at least two different times, bronchodilators and antihistamines without resolution of symptoms. His past medical history was significant for bronchitis as a child. Family history was noncontributory. He denied tobacco, alcohol or recreational drug use. He was a police officer and a hockey referee. His examination was unremarkable. Methacholine challenge test, CT chest, CPET and sleep studies were unremarkable. Albuterol inhaler occasionally relieved his symptoms. On further questioning about his symptoms he stated that when he tilts his head to one side was more short of breath. Following this information we proceeded with CT neck, which showed a right aryepiglottic fold mass. ENT evaluation was done which showed a 2 cm mass in the posterior pharynx. Microlaryngoscopy was performed the entire mass was isolated histology showed neurofibroma. Then the entire mass was removed.

DISCUSSION: Neurofibromas are not encapsulated and are often associated with NF-1. Due to its slow growth laryngeal neurofibroma can remain symptom free for years. The symptoms vary from slight hoarseness and discomfort in the throat to disturbances in breathing, cough and dyspnea according to the size and the location of the tumor. They occur more commonly in supraglottic area due to abundance of sensory nerve. Surgery is the treatment of choice. No malignant transformation has been documented.

CONCLUSIONS: The patient’s shortness of breath and cough was attributed to the laryngeal neurofibroma and removal of the mass relieved his symptoms. Among the huge differential diagnosis of shortness of breath the mechanism of our patient’s symptom is unusual. Thorough history taking and high index of suspicion is rewarding. Multidisciplinary team approach is necessary for the proper diagnosis and treatment of laryngeal neurofibroma.

Reference #1: 1. Yi- Wei Chen, MD; Tuan- Jen Fang, MD; Hsueh-Yu Li, MD. Chang gung medical journal vol.27, no.12

Reference #2: 2. Thomas T smith - Archives of otolaryngology 1944; 39(2): 144-151

Reference #3: 3. Yu- Chun Chen, Kuo-Sheng Lee, Cheng-Chien Yang, Ke- Chang Chang - International journal of pediatric otorhinolaryngology 65(2002) 167-170

DISCLOSURE: The following authors have nothing to disclose: Madhuri Kamatham, Robert Holladay

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Chest. 2013;144(4_MeetingAbstracts):13A. doi:10.1378/chest.1702634

SESSION TITLE: Airway Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Amyloidosis is a rare disease caused by extracellular deposition of amyloid. Isolated pulmonary amyloidosis requires the absence of systemic amyloidosis and can appear as parenchymal nodules, diffuse parenchymal infiltrates or submucosal deposits in the airways1.

CASE PRESENTATION: 58-year-old healthy male from Peru, lifetime non-smoker, dental laboratory technician developed productive cough, chest pressure and dyspnea. He was hospitalized with left lower lobe pneumonia and treated with broad-spectrum antibiotics. He was readmitted two weeks later for ongoing dyspnea, cough, weight loss and acute renal failure. Chest radiograph showed a persistent left basilar opacity. Computed tomography of the chest revealed endobronchial polypoid lesions and enlarged mediastinal and hilar lymph nodes. PET showed hypermetabolic right paratracheal, subcarinal and bilateral hilar lymphadenopathy. Bronchoscopy demonstrated numerous polyps along the main carina, bronchus intermedius and distal left mainstem bronchus with partial left lower lobe bronchial obstruction. Bronchial brushings and bronchoalveolar lavage were negative for malignant cells; endobronchial biopsy inconclusive. Patient was evaluated at our institution for a second opinion. His vital signs were stable and physical exam was unrevealing. Bronchoscopy confirmed prior findings. EBUS-TBNA of level 4R and 7 lymph nodes, endobronchial debulking of left lower lobe nodules and Nd:YAG laser treatment were performed. Pathology showed AL-type amyloidosis, associated with monotypic plasmacytosis. TBNA of level 7 lymph node was positive for abundant amyloid and negative for malignant cells. Blood work revealed BUN 48, creatinine 5, sedimentation rate >100, HIV negative, p-ANCA positive and c-ANCA negative. Serum and urine protein electrophoresis were normal. Renal biopsy demonstrated p-ANCA associated crescentic glomerulonephritis without evidence of amyloid. Workup for systemic amyloidosis including bone marrow aspirate, fat pad aspirate and cardiac MRI was negative.

DISCUSSION: Tracheobronchial amyloidosis demonstrates diffuse submucosal deposition of amyloid plaques and nodules along the airways with varying degrees of obstruction 1. It presents with recurrent pneumonia, respiratory failure and may mimic bronchogenic carcinoma. Management includes observation, intermittent bronchoscopic resection or laser therapy 2,3.

CONCLUSIONS: Tracheobronchial amyloidosis should be considered in differential diagnosis of recurrent pneumonia. Bronchoscopy is required for establishing diagnosis by tissue biopsy and for treatment.

Reference #1: O’Regan A et al .Tracheobronchial amyloidosis: the Boston University experience from 1984 to 1999. Medicine 2000; 79, 69-79

Reference #2: Hui AN et al. Amyloidosis presenting in the lower respiratory tract. Arch Pathol Lab Med. 1986;110, 212-8

Reference #3: Cordier JF et al. Amyloidosis of the lower respiratory tract. Clinical and pathologic features in a series of 21 patients. Chest. 1986; 90, 827-31

DISCLOSURE: The following authors have nothing to disclose: Elvina Khusainova, Mohit Chawla

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Topics: pneumonia
Chest. 2013;144(4_MeetingAbstracts):14A. doi:10.1378/chest.1704789

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Granular Cell Tumors (GCT) are rare tumors of Schwann cell origin mostly found in skin, mouth, and tongue. GCT of the lung account for 6-10% of all GCT. This case illustrates the value of careful review of radiologic characteristics, utility of endobronchial ultrasound (EBUS), and limitations of mediastinoscopy in establishing the diagnosis of paratracheal lesions.

CASE PRESENTATION: A 36-year-old nonsmoking woman with asthma presented for evaluation of a right paratracheal mass found on CT scan obtained in 2008. She underwent mediastinoscopy revealing benign lymphoid tissue. There was no follow up of the mass as it was assumed the mediastinoscopy was definitive. Four years later she had a repeat CT chest for evaluation of right shoulder pain. The mass had increased by 1 cm from her previous CT scan. She was otherwise asymptomatic, including resolution of the shoulder pain. Her physical exam was normal. PET/CT revealed the mass to have a SUVmax: 4.8, increased from SUVmax: 2.5 in 2008. No other lesions were noted on PET/CT. She underwent bronchoscopy showing no endobronchial lesions. EBUS-TBNA sampling of the mass revealed sheets/nests of mesenchymal cells with abundant granular cytoplasm that stained s-100 positive, consistent with a GCT.

DISCUSSION: GCT are often benign, slow growing tumors that can infiltrate locally. Presenting symptoms include hemoptysis, chest pain, and post-obstructive pneumonia. GCT can be difficult to differentiate from other tumors. Pathologic staining differentiates them, with GCT staining positive for s-100 and vimentin. Surgical resection is the current treatment of choice although localized therapy including Nd: YAG Laser and Argon Plasma Coagulation (APC) have been used successfully for endobronchial lesions. Given our patient’s young age, tumor proximity to trachea, and growth pattern, she was advised to undergo surgical resection.

CONCLUSIONS: This is a case of right paratracheal mass diagnosed as a GCT via EBUS-TBNA after negative sampling by mediastinoscopy. Since the mass was intra-parenchymal, mediastinoscopy was unable to access it through the tissue planes resulting in removal of a benign lymph node instead. The mass was better characterized with EBUS. This case demonstrates the importance of multi-disciplinary approach and appropriate selection of diagnostic modality for paratracheal lesions. A normal lymph node sampling, as in our case, via mediastinoscopy does not necessarily rule out tumor. In fact, follow up imaging in conjunction with use of a different diagnostic modality may improve diagnostic yield.

Reference #1: Deavers M, et al. Granular Cell Tumors of the Lung. Clinicopathologic Study of 20 cases. Am J Surg Pathol 1995; 19: 627-35.

Reference #2: Van Der Maten J, et al. Granular Cell Tumors of the Tracheobronchial Tree. J Thorac Cardiovasc Surg 2003; 126: 740-3.

DISCLOSURE: The following authors have nothing to disclose: Ellen Marciniak, Julia Choi, Ashutosh Sachdeva, Janaki Deepak

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Chest. 2013;144(4_MeetingAbstracts):15A. doi:10.1378/chest.1705160

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Glomus tumors are a rare disease entity, most commonly arising from the skin, subungal tissues, or the extremities. We present a case of airway obstruction caused by a glomus tumor relieved by rigid bronchoscopy and diode laser treatment.

CASE PRESENTATION: A 51 year old male with a twenty pack year history of tobacco abuse presented to the emergency room with intermittent chest pain and shortness of breath occurring over the prior month. Cardiac workup was unremarkable, and a chest CT demonstrated a left main stem bronchial lesion. Flexible bronchoscopy was performed and demonstrated an obstructing lesion in the proximal left mainstem, with a ball-valve effect with cough, causing it to obstruct the trachea. Endobronchial biopsies confirmed a glomus tumor. The patient subsequently underwent rigid bronchoscopy with mechanical debridement of the tumor and diode laser application to the stalk of the tumor along the posterior wall of the left mainstem bronchus. Followup flexible bronchoscopy four months later demonstrated no recurrence, and at twelve months, he remains disease free.

DISCUSSION: Glomus tumor was first described in 1924 by Masson, and the first tracheal tumor reported in 1950 by Hussarek1. Though often benign in nature, these tumors may cause clinically significant airway obstruction necessitating intervention. To date, less than thirty such cases have been identified in the literature, most commonly requiring surgical resection. In eight cases, endobronchial obstruction was relieved by rigid or flexible bronchoscopy with other ablative methods including Nd:Yag, APC, and electrocautery. This is the first case to our knowledge of successful tumor removal exclusively with rigid bronchoscopy and diode laser.

CONCLUSIONS: This case adds to the literature regarding this rare disease entity. Bronchoscopic therapy combined with available ablative techniques is becoming increasingly common and successful.

Reference #1: Colaut F. Tracheal Glomus Tumor Successfully Resected with Rigid Bronchoscopy. A Case Report. Journal of Thoracic Oncology. 2008;3:1065-1067.

DISCLOSURE: The following authors have nothing to disclose: Amit Goyal, Neeraj Desai, Kevin Kovitz, Sara Greenhill

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Chest. 2013;144(4_MeetingAbstracts):16A. doi:10.1378/chest.1705220

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Persistent pulmonary air leaks (PAL) is one of the indications for prolonged chest tube placement which itself is associated with significant morbidity, mortality and increased length of stay. The usual approach is to do a thoracoscopic or open surgical repair, however this can now be achieved with minimally invasive approach using IBV (Intra Bronchial Valve). We present a first case in which the PAL was treated with noninvasive pneumonectomy by placement of IBV valves.

CASE PRESENTATION: Our patient is an 84 y/o male with past medical history of Chronic Obstructive Pulmonary Disease, ischemic heart disease who presented with recurrent right sided pleural effusions as complication of abdominal aortic aneurysm repair. He had a chest tube placed for these recurrent effusions which was complicated by PAL however because of his cardio-pulmonary co-morbidities he wasn’t a candidate for open surgical repair. He had a V/Q scan to see the functional status of his lungs and was found to have differential perfusion of 88% to the Left lung and 12% to the Right lung. Patient had fiber optic bronchoscopy and the right upper lobe was occluded using IBV, however he continued to have diminished but persistent airleak for subsequent three days. He again underwent bronchoscopy and his entire right lung was occluded using nine IBV valves, effectively performing a non-invasive pneumonectomy for his poorly functioning lung, with no air leak identified on the water seal. Patient’s chest tube was discontinued the next day and he was discharged home subsequently. He was noted to be doing well in a follow-up visit.

DISCUSSION: The IBV valves are currently used as humanitarian device and currently under investigation for their use in PAL. There are currently multiple case reports in the literature demonstrating the use of IBV valves for PAL by occluding several segments in the lung however we couldn’t find any cases describing a total occlusion of a lung. By performing a non-invasive pneumonectomy on our patient we were able to improve his quality of life as well as decrease the co-morbities associated with PAL.

CONCLUSIONS: IBV valves can be used as one of the therapeutic options for minimally invasive treatment option for PAL.

Reference #1: Sterman DH et al. A multicenter pilot study of a bronchial valve for the treatment of severe emphysema. Respiration 2010;79:222-33.

Reference #2: Travaline J et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009;136:355-60.

DISCLOSURE: The following authors have nothing to disclose: Killol Patel, Navneet Arora, Chaitali Gupte, Irtza Sharif, Pratik Patel

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Chest. 2013;144(4_MeetingAbstracts):17A. doi:10.1378/chest.1702872

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheobronchomegaly (Mounier-Kuhn Syndrome) is a rare disease in which chronic ventilation poses unique challenges due to the airway diameter and collapsibility(1). Although a tracheostomy cuff may permit ventilation, this may be impeded by significant expiratory collapse of the airways into the distal tracheostomy with exhalation. We present a unique technique for stabilizing the airway and permitting long-term ventilation for this complex clinical scenario.

CASE PRESENTATION: A 73 year old was transferred to our facility after failed attempts to ventilate the patient due to a combination of tracheobronchomegaly, diffuse expiratory airway collapse and ongoing bronchopneumonia. His trachea measured 46 x 37 mm and his mainstem bronchi measured 22 mm on the right and 21mm on the left. Despite several tracheostomy attempts using standard and extra-long cuffed tracheostomy tubes, the expiratory airway continued to collapse into the distal tracheostomy prohibiting effective ventilation. Tracheoplasty was not feasible due to the patient’s critical illness. A silicone Y-stent (Boston Medical) measuring 18 x 14 x 14 mm was placed into his tracheobronchial tree. The stent provided bronchoscopically confirmed stabilization of his bronchomalacia, but ventilation remained problematic. Although the inspiratory airflow was sufficient, a large air leak with “back-flow” around the stent and tracheostomy tube was persistent due to inadequate apposition of tubes to the tracheobronchial airways. The patient’s true ventilation was less than 20% of that provided by the ventilator, with exhaled tidal volumes less than 100 ml with an inspiratory volume set at 500 ml. Due to persistent failure, a Bivona® Fome-Cuf® (Smiths Medical) tracheostomy tube was then intussuscepted into the tracheal limb of the Y stent. With approximately 50% of the tracheostomy inside of the stent, the superior portion of the cuff remained external to the stent and with inflation, provided complete apposition to the severely dilated tracheal wall. By stabilizing the distal trachea and mainstem bronchi with a Y stent and by using the cuff of the tracheostomy in the trachea, adequate ventilation was restored.

DISCUSSION: Chronic ventilation in patients with tracheobronchomegaly is complicated due to pathologically dilated and collapsible airways. We were able to provide ventilation when intussuscepting a Bivona® cuffed tracheostomy tube into a tracheobronchial Y stent, stabilizing the diffuse airway collapsibility while ensuring apposition of the tracheostomy tube to the tracheal wall.

CONCLUSIONS: To our knowledge, very few, if any, other options exist for this clinical scenario.

Reference #1: (1) Odell DD, Shah A, et al., Airway stenting and tracheobronchoplasty improve respiratory symptoms in Mounier-Kuhn syndrome. Chest. 2011 Oct;140(4):867-73.

DISCLOSURE: The following authors have nothing to disclose: Christopher Erb, Kelsey Johnson, Margaret Pisani, Jonathan Puchalski

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Chest. 2013;144(4_MeetingAbstracts):18A. doi:10.1378/chest.1703322

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: PTLD in lung transplantation has a higher incidence than all other solid organs, with earlier presentation within the thorax. PTLD requires histological morphology, immunophenotype, clonality and in situ testing for Epstein Barr Virus-encoded RNA (EBER) for complete diagnosis since this will greatly impact therapy. We present a unique case of early PTLD using navigational bronchoscopy.

CASE PRESENTATION: 52 yo s/p heart redo-lung transplant for cardiomyopathy and Stage 3 bronchiolitis obliterans (EBV donor positive, recipient positive). He received rabbit thymoglobulin for renal protection as induction therapy and was maintained on a standard regimen of tacrolimus, mycophenolate and prednisone for immunosuppression and valgancyclovir for antiviral prophylaxis. Ten weeks post transplant he presented with fevers and generalized fatigue and underwent CT chest which revealed a right lower lobe nodule(1.5 cm) and left lower lobe nodule(1 cm). Fluro-2-deoxy-D-glucose (FDG-PET) scan demonstrated bilateral avid nodules(SUV max 7.4 and 7 respectively). He subsequently underwent an electromagnetic navigation bronchoscopy(ENB) with peripheral EBUS(superDimenson, iLogic system Plymouth MN, USA) where RLL nodule transbronchial needle aspiration was performed using supertrax needle and fluoroscopically guided transbronchial biopsies were sent for pathology. Histopathological examination of the transbronchial biopsy revealed Epstein-Barr Virus(EBV) associated B-cell lymphoproliferative disorder. Immunohistochemical stains and chromogenic in situ hybridization for EBER were positive. In addition, flow cytometry of the transbronchial fine needle aspirate had monotypic kappa B-cell population consistent with post-transplant lymphoproliferative disorder(PTLD).

DISCUSSION: To the best of our knowledge ENB guided transbronchial biopsies have not been used previously to successfully diagnose PTLD. Above we present an unusual case of pure lung involvement of PTLD where navigational bronchoscopy and transbronchial biopsies led to a prompt positive diagnosis, obviating the need for more invasive procedures such as a surgical lung biopsy for more tissues. Adequate tissue samples are needed for diagnosis and ancillary testing to provide insight into additional features of PTLD that might be necessary to guide appropriate therapy.

CONCLUSIONS: ENB with EBUS and transbronchial biopsies may be a useful means of diagnosing pulmonary PTLD and avoiding more invasive techniques to obtain adequate tissues sample for histopathology and ancillary testing.

Reference #1: Post transplant Lymphoproliferative Disease after Lung Transplantation. Neuringer, IP

Reference #2: Pulmonary nodules in lung transplant recipients: etiology and outcome. Lee P, Minai OA, et al

Reference #3: Lung retransplantation after posttransplantation lymphoproliferative disorder (PTLD): a single-center experience and review of literature of PTLD in lung transplant recipients. Raj R, Frost AE

DISCLOSURE: The following authors have nothing to disclose: Dhruv Joshi, Thomas Gildea, Marie Budev

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Chest. 2013;144(4_MeetingAbstracts):19A. doi:10.1378/chest.1703787

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: A right-sided aortic arch (RAA) is a rare anomaly of the cardiovascular system. We report a case of (RAA) in a patient with mediastinal lymphadenopathy finally diagnosed as sarcoidosis. Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) played a significant role in obtaining a sufficient tissue sample to make the diagnosis.

CASE PRESENTATION: A 27-year-old man presented history of progressive dry cough with mild shortness of breath, low grade fevers and night sweats. He was well built, never-smoker, and working as a police officer. Physical examination of the chest revealed increase of bronchial sounds on both lung fields, heart exam was unremarkable for any extra heart sounds or murmurs and the rest of the exam was normal. Radiographic examination of the chest showed right paratracheal mass displacing the trachea to the left. CT scan of the chest revealed a right-sided aortic arch with mediastinal and hilar adenopathy. Based on the radiographic findings the patient underwent EBUS-TBNA. The bronchoscopy showed diffused cobblestone of the airway. The EBUS identified the aortic arch on the right side of the tracheal wall, out-layering the superior vena cava vein. Multiple ultrasound guided TBNA were obtained from the lymphnodes stations which revealed multiple non-caseating granulomas. The final diagnosis was sarcoidosis.

DISCUSSION: Right aortic arch is a rare cardiovascular anomaly caused by interruption in the development of the third and fourth branchial arch in embryologic life. Patients with this cardiovascular anomaly are usually asymptomatic, however in some cases, cyanotic congenital heart disease like tetralogy of Fallot has been reported with RAA, these patients are usually diagnosed in fetal life or early childhood. On plain chest X-ray, RAA is recognized as the aorta descends on the right of the air-filled trachea. CT chest angiography can make the diagnosis as the left or right sidedness of the aortic arch refers to the position of the aortic arch relative to the trachea . RAA ultrasound findings described in literature are mainly in fetal life. We present a case of RAA with mediastinal lymph adenopathy with the EBUS findings of the RAA. EBUS-TBNA was performed with no complications, which emphasize the importance of using EBUS in such cases with cardiovascular anomalies to minimize the rate of catastrophic outcomes.

CONCLUSIONS: EBUS-TBNA can be helpful in some cases of cardiovascular anomalies that mandate mediastinal lymph nodes transbronchial needle aspiration due to its role in easy identification of vascular vs. nonvascular structures.

Reference #1: Knight L and Edwards JE. Right aortic arch. Types and associated cardiac anomalies. Circulation. 1974;50(5):1047-1051

Reference #2: Ha GJ, Sung MJ, Lee YS et al. A case of right sided aortic arch combined with atrial septal defect. Journal of cardiovascular ultrasound. 2011;19(1):32-34

DISCLOSURE: The following authors have nothing to disclose: Abdul Hamid Alraiyes, Khalid Alokla, Fayez Kheir, Jaime Palomino

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Chest. 2013;144(4_MeetingAbstracts):20A. doi:10.1378/chest.1703075

SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Cryodebridement of malignant endobronchial lesions can be used as a palliative treatment to improve dyspnea and quality of life.

CASE PRESENTATION: A 57 year-old male was diagnosed with cutaneous melanoma of the left posterior shoulder in 2009. He underwent wide local excision and regional lymph nodes were negative for metastases. In 2010 a PET CT showed uptake in a level V lymph node of the neck that was confirmed to be malignant melanoma. Treatment consisted of radiation therapy and five cycles of Temodar. In 2012 a CT of the chest was obtained to evaluate increasing dyspnea; it identified an endobronchial lesion in the distal left mainstem bronchus. Bronchoscopy revealed a large endobronchial lesion occluding the entrance to the left upper lobe (fig 1), confirmed to be malignant melanoma on biopsy. Debridement using cryotherapy was performed to improve dyspnea and reduce the risk of post-obstructive infections(fig 2). Given the need for multiple passes with the bronchoscope, we performed the procedure under moderate to deep sedation with an artificial airway in place. This was accomplished on an outpatient basis and he was discharged on the same day with improved symptoms.

DISCUSSION: Malignant melanoma can metastasize to the lung in up to 19% of affected patients.1 The role of cryotherapy in malignant endobronchial disease is palliative. Patient selection should include those with short endobronchial lesions with patent distal airways where symptoms are at least partially attributable to the lesion of interest.2 Cryotherapy has an excellent safety profile. Collagen, cartilage and other poorly vascularized tissues that support the respiratory tree are cryo-resistant due to the low vascularity of these tissues.3 Side effects include transient fever and sloughing of material that can lead to airway obstruction.3

CONCLUSIONS: Cryotherapy is a reasonable approach for palliation in patients with metastatic endobronchial malignancies where the lesion is short and there are patent airways distal to the lesion.

Reference #1: Meyer T, Merkel S, Goehl J, Hohenberger W: Surgical Therapy for Distant Metastasis of Malignant Melanoma. Cancer 2000; 89:1983-1991.

Reference #2: Eiler B, Savy FP, Melloni B, Germouty JD. Tumoral Tracheobronchial Obstruction by Cryotherapy Using a Flexible Catheter. Presse Med, 1988; 17:2138-2139.

Reference #3: Vergnon JM, Huber RM, Moghissi K. Place of Cryotherapy, Brachytherapy, and Photodynamic Therapy in Bronchoscopy of Lung Cancers. EurRespir J 2006; 28: 200-218.

DISCLOSURE: The following authors have nothing to disclose: William Parker, Ramez Sunna

No Product/Research Disclosure Information

Topics: melanoma , cryotherapy
Chest. 2013;144(4_MeetingAbstracts):21A. doi:10.1378/chest.1705183

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Mediastinal masses in both adults and children are concerning for malignancy, especially thymomas and lymphomas. Benign tumors may be present as well. When cystic lesions are found in the mediastinum, they tend to be bronchogenic, thymic, or pericardial. Solitary cystic mediastinal lymphangioma is rare and almost exclusively found in the pediatric population, most commonly in the head and neck region.

CASE PRESENTATION: A 62 year-old male pipe smoker with a history of prostate cancer presented to the emergency department with new onset atrial fibrillation. A right paratracheal mass was incidentally found on CT chest and he was referred to pulmonary clinic for further evaluation. EBUS-TBNA was performed showing a 24mm cystic appearing lesion in the 4R region and TBNA drained 29 mL of cystic fluid. Cytology was negative for malignant cells and repeat chest CT showed significant decrease in size of the mass with a presumptive diagnosis of benign bronchogenic cyst. Follow-up CT two months later showed recurrence of the cyst, although he remained asymptomatic. He opted for resection and was taken for VATS. Pathology returned with the diagnosis of lymphangioma.

DISCUSSION: Cystic mediastinal lymphangioma (CML) is an extremely rare vascular tumor originating from lymphatic vessels. Less than 1% occur in the mediastinum and greater than 90% discovered before the age of 2. Usually an incidental finding, CML is benign but may compress local structures or become infected. It's appearance on CT often resembles adenopathy or a mass. In our adult pipe smoking patient with a personal history of cancer, malignancy needed to be excluded. EBUS-TBNA has been reported as a treatment for CML however recurrence occurred after 2 months in our patient. Diagnosis was not made until surgical resection as it was initially thought to be a bronchogenic cyst. Although recurrence has been reported following surgery, sclerotherapy is emerging as a promising treatment option.

CONCLUSIONS: Lymphangioma is a benign yet rare cause of mediastinal cyst and often mimics malignancy. Surgical resection and sclerotherapy may be curative.

Reference #1: Takeda S, Miyoshi S, Minami M, et al. Clinical spectrum of mediastinal cysts. Chest 2003; 124(1):125-32.

Reference #2: Khobta N, ZTomasini P, Trousse D, et al. Solitary cystic mediastinal lymphangioma. Eur Respir Rev 2013;22(127):91-93.

Reference #3: Choi SH, Kim L, Lee KH, et al. Mediastinal lymphangioma treated using endobronchial ultrasound-guided transbronchial needle aspiration. Respiration 2012;84:518-521.

DISCLOSURE: The following authors have nothing to disclose: Joseph Khabbaza, Sonali Sethi, Daniel Raymond, Francisco Almeida

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Chest. 2013;144(4_MeetingAbstracts):22A. doi:10.1378/chest.1702297

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Amyloidosis is an unusual cause of mediastinal lymphadenopathy. Systemic amyloidosis can manifest as either mediastinal or hilar lymph node enlargement. Localized amyloidosis presenting as intrathoracic lymphadenopathy is extremely rare . Our case illustrates the first known case report of solitary, inthrathoracic, amyloidosis diagnosed by EBUS-TBNA.

CASE PRESENTATION: 64 year-old male with a 30 pack-year smoking history who presented with an incidental finding of a large calcified, heterogenous right paratracheal mass on noncontrast CT. He denied any constitutional symptoms. There were no abnormalities found on physical exam. PET CT scan showed a 3.2 x 2.5 cm right paratracheal mass (SUVmax = 4.0) with central calcifications and areas of low density. Bronchoscopy with TBNA revealed a bloody specimen with normal flow cytometry and negative AFB cultures. EBUS-TBNA was performed with five passes to the right paratracheal mass at the 4R location. Final cytopathology revealed acellular material consistent with amyloid, which was confirmed on Congo Red stain. He subsequently underwent serum and urine electrophoresis as well as a bone marrow biopsy which were both unrevealing.

DISCUSSION: Amyloidosis is a heterogeneous group of disorders characterized by extracellular deposition of abnormal protein and protein derivatives in a β -pleated configuration that makes the proteins resistant to proteolysis . Chest radiography shows characteristic lymphadenopathy with homogeneous low attenuation and stippled or faint calcification is a characteristic finding of amyloidosis. Some enlarged lymph nodes have been reported to show coarse, patchy or punctate calcification.

CONCLUSIONS: Case reports of intrathoracic amyloid have been diagnosed with percutaneous needle aspiration, mediastinaoscopy, open surgical biopsy, or post-mortem examination. With the advent of EBUS-TBNA patients with such a rare finding can be diagnosed without surgical intervention.

Reference #1: Urschel JD, Urschel DM. Mediastinal amyloidosis. Ann Thorac Surg 2000;69:944-6

Reference #2: Pickford HA, Swensen SJ, Utz JP. Thoracic cross-sectional imaging of amyloidosis. AJR Am J Roentgenol 1997;168:351-5

Reference #3: Borge MA, Parker LA, Mauro MA. Amyloidosis: CT appearance of calcified, enlarged periaortic lymph nodes.J Comput Assist Tomogr 1991;15:855-7

DISCLOSURE: The following authors have nothing to disclose: Sachin Patel, Matthew Barrett, Edward Pickering, Janaki Deepak

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):23A. doi:10.1378/chest.1703301

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Synthetic cannabis is a psychoactive designer drug derived from natural herbs and sprayed with synthetic chemicals that can mimic the effects of cannabis. It is best known by the brand names K2 and Spice. Even though synthetic cannabis appeared in the early 2000s, research on its safety is becoming available now and only concentrates on the psychiatric disorders[1]. Only one case report on pulmonary complications of smoking this drug has been published in the past[2].

CASE PRESENTATION: A 44 year-old woman presented to the hospital with a five day history of fever, productive cough and dyspnea. She had past medical history of HIV diagnosed three years prior. She was off highly active antiretroviral therapy. Her CD4 count was 3.4 UL and viral load was 250,000 copies/ml on presentation. She also reported having multiple treatments for pneumocyctis jiroveci pneumonia. She was being treated for non tuberculous mycobacteria on clarithromycin, ethambutol and rifabutin. Social history revealed remote history of smoking in her 20’s, however for the past four years she has been smoking Spice, a synthetic cannabinoid. She denied cocaine or other drug usage. On admission her complete blood cell count, urine analysis and serum electrolytes were normal. Blood culture and sputum culture showed no growth. Chest x ray showed airway opacities on the right middle lobe suggestive of pneumonia. CT scan of the chest revealed patchy airspace disease in upper lobes bilaterally. Extensive work up was performed including negative serology for toxoplasma, histoplasma, legionella, and Cryptococcus and blastomycosi. She was started on broad spectrum antibiotics for possible bacterial infection, atovaquone for PJP and clarithromycin, ethambutol and levofloxacin for mycobacterial infection. Bronchoscopy revealed normal airway however on BAL, black colored, carbnaceous fluid was returned. Transbronchial biopsies were also black.

DISCUSSION: The findings of carbonaceous material in the BAL of cocaine users and occupational exposures such as silica, metal and alloids have been described in the past. Pulmonary complications may result from impurities inhaled during the process of cocaine smoking or occupational exposures. We propose that these synthetic cannabinoids can do the same by a similar mechanism.

CONCLUSIONS: Black carbonaceous fluid is a BAL finding in users of synthetic cannabis.

Reference #1: Hermanns-Clausen, M., et al., Acute toxicity due to the confirmed consumption of synthetic cannabinoids: clinical and laboratory findings. Addiction, 2013. 108(3): p. 534-44.

Reference #2: Loschner, A., Diffuse Alveolar Hemorrhage: Add “Greenhouse Effect” to the Growing List. Chest, 2011. 140(4).

Reference #3: Klinger, J.R., E. Bensadoun, and W.M. Corrao, Pulmonary complications from alveolar accumulation of carbonaceous material in a cocaine smoker. Chest, 1992. 101(4): p. 1171-3.

DISCLOSURE: The following authors have nothing to disclose: Kerron Catlyn, Natalia Moguillansky, Hiren Mehta, Michael Jantz, Vipul Patel

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):24A. doi:10.1378/chest.1704933

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: The increase of intracranial pressure (ICP) secondary to fluctuation of intrathoracic tension can be significant during bronchoscopy, Previous studies concluded that flexible bronchoscopy (FB) carries a low risk in patients with elevated ICP. Endobronchial Ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) of lymph nodes requires a longer procedural duration. There is currently no guideline report on the safety of EBUS in patients with intracranial mass (ICM). We present two cases where EBUS-TBNA was performed without complications.

CASE PRESENTATION: Case 1: 58 year old male presented with right sided weakness. Computed Tomogram (CT) head showed hemorrhagic lesions with mass effect and midline shift and a CT chest showed parenchymal masses with lymphadenopathy. Decadron was initiated for 2 days. The EBUS-TBNA and transbronchial biopsy (TBB) confirmed a diagnosis of Adenocarcinoma of the lung. There was no change in his respiratory or neurological status during or after the procedure. Case 2: 71 year old male presented with vomiting and headaches. CT head showed multiple large low-density abnormalities with mass effect and a CT chest showed nodules with lymphadenopathy. He was on Decadron for 5 days. The EBUS-TBNA and TBB, confirmed a diagnosis of Adenocarcinoma of the lung. He received Propofol and Rocurorium. Post procedure he remained stable with no neurological symptoms

DISCUSSION: EBUS-TBNA is an essential diagnostic tool in thoracic malignancies. Patients may often present with neurological symptoms as a result of metastatic brain masses and mediastinal lymphadenoapthy. During FB, the ICP rapidly increased in 81% cases and the mean highest ICP was 38.0mm Hg. Localized cerebral ischemia and herniation may be precipitated. We performed EBUS-TBNA under general anesthesia and paralytics. Both patients received pre-procedural steroid for at least 48 hours. The possible rise in arterial pressure probably maintained the perfusion even though the ICP might have increased. The use of paralytics during EBUS may have prevented sudden rise in pressure to avoid herniation

CONCLUSIONS: EBUS-TBNA can be performed safely without any neurological or respiratory sequelae in patients with metastatic ICM and neurological manifestations under general anesthesia with paralysis

Reference #1: Lee T. Fiberoptic bronchoscopy and intracranial pressure. Chest. 1994;105:1909.

Reference #2: Bajwa MK. Fiberopticbronchoscopy in the presence of space-occupying Lesions.. intracranial lesions. Chest1993;104:101

Reference #3: Kerwin AJ. Effects of fiberoptic bronchoscopy on intracranial pressure in patients with brain injury:a prospective clinical study.l .J Trauma. 2000;48

DISCLOSURE: The following authors have nothing to disclose: Mohamed Ali, Shaheen Islam, Abdulgadir Adam

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):25A. doi:10.1378/chest.1702046

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheobronchopathia Osteochondroplastica (TO) is a rare non-neoplastic condition of the trachea, major airways, and occasionally larynx. It manifests as benign growths of osseous and cartilaginous nodules arising in the submucosa. Frequently asymptomatic, TO has been associated with numerous respiratory manifestations, including haemoptysis, dyspnoea, cough, lobar collapse, and lower respiratory infections.

CASE PRESENTATION: A 57 year old man was found incidentally to have right middle lobe (RML) bronchiectasis and partial collapse on computerized tomography (CT) following a motor vehicle accident. A chronic cough productive of discoloured sputum was reported. The patient emigrated from Turkey to Australia 24 years earlier. He worked as a metal welder and painter. His father had tuberculosis as a child. Comorbidities include a 10-pack year ex-smoking history and hypertension. He is a fit man who swims daily. While Quantiferon testing was positive, 3 sputum cultures for mycobacteria were negative. Spirometry and single breath gas transfer were normal. Bronchoscopy demonstrated multiple irregular nodules along the trachea and upper main bronchi. RML washings grew Pseudomonas aeruginosa and Klebsiella ozaena. Narrowing of the RML origin was not seen. Biopsies of a tracheal nodule demonstrated mucosa containing metaplastic bone and surface squamous metaplasia. Macroscopic and histological findings were consistent with TO. Antibiotics were prescribed. Four months later, repeat CT demonstrated improved RML changes, while repeat bronchoscopy one year later demonstrated stability of tracheal nodules.

DISCUSSION: Prior to CT and bronchoscopy, TO was diagnosed only on autopsy. Its true incidence remains unknown. The differential diagnoses include relapsing polychondritis, amyloidosis, Wegener's granulomatosis, endobronchial sarcoid, malignancy and tuberculosis. Biopsy for histopathological confirmation is therefore important. TO associated with lower respiratory infections has been well described. A previous case study described 2 patients with TO and RML collapse. In contrast to this case, both had RML origin narrowing.

CONCLUSIONS: Despite being a benign condition, TO is associated with a variety of chronic respiratory manifestations. Patients presenting in this manner warrant bronchoscopy as part of the diagnostic algorithm. Additionally, biopsy of endobronchial and endotracheal abnormalities for pathological diagnosis is vital.

Reference #1: Pounder DJ, Pieterse AS. Tracheopathia osteoplastica: report of four cases. Pathology. 1982 Oct;14(4):429-33

Reference #2: Lundgren R, Stjernberg NL. Tracheobronchopathia osteochondroplastica. A clinical bronchoscopic and spirometric study. Chest. 1981 Dec;80(6):706-9.

Reference #3: Hodges MK, Israel E. Tracheobronchopathia osteochondroplastica presenting as right middle lobe collapse. Diagnosis by bronchoscopy and computerized tomography. Chest. 1988 Oct;94(4):842-4.

DISCLOSURE: The following authors have nothing to disclose: Kovi Levin, Eli Dabscheck

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Chest. 2013;144(4_MeetingAbstracts):26A. doi:10.1378/chest.1705314

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: There are numerous causes of hemoptysis. We present an usual cause of massive hemoptysis.

CASE PRESENTATION: A 34 year old lady presents to the emergency department complaining of hemoptysis. She coughed more than 200ml of blood within the last 2 hours prior to admission. Hemoptysis had stopped upon arrival to the emergency department. The patient has had episodes of hemoptysis in the past that were self limiting and comprised of coughing blood streaked sputum. The patient has a past medical history significant for a giant cell tumor involving the sixth thoracic vertebra that was resected in 2007. The tumor recurred and upon follow up in 2010 the mass had enlarged to 10cm in diameter and had invaded three vertebral bodies and four ribs. She underwent radiation therapy and chemotherapy, followed by tumor resection, spinal fixation and right lung lower lobe partial resection in 2011. The patient was admitted to the ICU for observation. A CT angiogram of the chest revealed a right bronchopleural fistula and a right paraspinal screw within the fistula. A bronchoscopy was performed. A paraspinal screw was seen at the distal end of the broncus intermedius, transversing the subcarina from the medial to lateral aspect. The thoracic and neurosurgical services operated on the patient. Due to instability of her spine, they opted to perform a right middle lobe resection and a stump was created at the end of the bronchus intermedius. A repeat bronchoscopy revealed a well healed stump at the end of the bronchus intermedius.

DISCUSSION: The patient has had previous self limiting episodes of hemoptysis that were attributed to the surgery, partial lower lobe lobectomy. Previous CT images of the chest performed prior to this admission had commented on a “possible” bronchopleural fistula yet never on the location of the paraspinal screw.

CONCLUSIONS: This case underlines the importance of bronchoscopy in localizing and controlling the source of bleeding if the source of bleeding is unknown1. The direct visualization of the source of bleeding can guide therapy and clarify ambiguities noted on imaging of the chest.

Reference #1: Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin. Chest Med. 1994;15(1):147-167

DISCLOSURE: The following authors have nothing to disclose: Mohammed Alzoubaidi, Wendy Hsu, Wei Shen, Dena L'heureux

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):27A. doi:10.1378/chest.1705264

SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchopleural fistulae (BPF) are an uncommon but severe complication of lung resection surgery. Endoscopic treatment of persistent leak due to small peripheral BPF has become increasingly common with the use of the Spiration IBV® (Spiration, Redmond, WA) valve. In cases of larger more central leaks not amenable to valve placement, Amplatzer® Atrial Septal Occluder (St. Jude Medical, St. Paul, MN) device placement has been reported1. We report successful placement of this device in two patients.

CASE PRESENTATION: Patient 1 - A 64-year-old female with adenocarcinoma of the lung underwent right-sided pneumonectomy. She subsequently developed dehiscence and a BPF at the right main stem stump, chronic empyema with frequent hospitalization, and permanent chest tube demonstrating persistent air leak. Bronchoscopic evaluation demonstrated a 12mm communication at the right main stem stump with the pleural space and Amplatzer® device was deployed successfully. Air leak improved immediately, and the patient has been admitted only once in the subsequent 15 months with exacerbation of symptoms. Patient 2 - A 70 year-old male with squamous cell lung cancer underwent right middle and lower lobectomy. He subsequently developed a continuous air leak, requiring placement of 4 IBV valves in the right upper lobe with resolution of the air leak at an outside institution. A large right-sided hydropneumothorax with empyema returned shortly after discharge requiring chest tube placement. Bronchoscopic evaluation demonstrated a 3 mm BPF at right lower lobe stump. Amplatzer® device was placed with resolution of the air leak. Post procedure, chest tube drainage decreased gradually and chest tube was removed two weeks later.

DISCUSSION: Spiration IBV® valves have demonstrated efficacy in closure of small peripheral BPFs, though fistula size or inability to anchor limits its use in stump leaks. In each of the above cases, the size and location of the fistulae prevented placement of a valve, or the ability to apply other sealants and required a different approach.

CONCLUSIONS: Amplatzer® device placement has been described as a novel solution to large central BPF. Our cases support the experience with these devices to date in select patients.

Reference #1: Fruchter O et al. Endobronchial Closure of Bronchopleural Fistulae Using Amplatzer Devices: Our Experience and Literature Review. Chest 2011:139:682-687.

DISCLOSURE: The following authors have nothing to disclose: Amit Goyal, Sara Greenhill, Kevin Kovitz, Neeraj Desai

The Amplatzer device is not approved for treatment of bronchopleural fistula.

Chest. 2013;144(4_MeetingAbstracts):28A. doi:10.1378/chest.1701154

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: We present a patient with persistent cough, worsening shortness of breath and bilateral pulmonary infiltrates that was found to have large bronchial casts and pathology confirmed the rare diagnosis of Plastic Bronchitis.

CASE PRESENTATION: A 61 year old male with history of chronic bronchitis on home oxygen therapy had multiple hospital admissions for recurrent fever, productive cough, bad taste and worsening dyspnea. He received multiple courses of antibiotics although previously no pathogenic organisms were isolated. His physical examination showed oxygen saturation of 84% on room air and bilateral wheezing. The immunological and vasculitis workup was negative. His IgE was 31, aspergillus precipitins and antibodies were negative. A year old CT chest (figure 1) showed bilateral pulmonary infiltrates and on the latest chest imaging there were multiple ground glass opacities (figure 2). The pulmonary function tests showed a progressive decline. Patient had a bronchoscopy done showing multiple bronchial casts (figure 3 and 4), which were removed. The histological specimen (figure 5) showed fibrin, mucin and neutrophil predominant cellular material which was consistent with diagnosis of inflammatory form of plastic bronchitis. He required multiple therapeutic bronchoscopies and was treated with both inhaled and high dose systemic steroids.

DISCUSSION: Plastic bronchitis has been described mostly in children. There is expectoration of large bronchial casts, which are of more cohesive and rubbery consistency than ordinary mucus plugging. Ventilgeraeusch (sound of a fan) or Bruit de drapeau (sound of a flag snapping) is typically present if the casts are subtotally obstructing the airway. Radiologically either atelectasis or infiltrates can be seen. Type 1 inflammatory form is characterized by bronchial disease and inflammation with presence of fibrin, mucin and cellular material mostly eosinophils on histology. Whereas, type 2 acellular form is without inflammation and has mainly mucin with little fibrin and is mostly associated with cyanotic heart diseases1. Both forms have a high mortality. Our patient had type 1 inflammatory plastic bronchitis. This disease is a management challenge2 and the patients usually require frequent bronchoscopies to remove the casts. Macrolides3, steroids, acetylcysteine, rhDNAase and aerosolized tPA have been tried only based on anecdotal case reports.

CONCLUSIONS: Plastic Bronchitis which has a high mortality causes a wide range of pulmonary complaints. The patients usually require frequent therapeutic bronchoscopies to remove the bronchial casts. Although it has no definitive therapy, there is some success with anecdotal case reports based therapy.

Reference #1: Am J Respir Crit Care Med. 1997 Jan;155(1):364-70.

Reference #2: Am J Med Sci. 2008 Feb;335(2):163-9.

Reference #3: Pediatr Pulmonol. 2003 Feb;35(2):139-43.

DISCLOSURE: The following authors have nothing to disclose: Syed Ali Riaz, Priyank Desai, Brian Fouty

No Product/Research Disclosure Information

Topics: bronchitis
Chest. 2013;144(4_MeetingAbstracts):29A. doi:10.1378/chest.1704857

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: Endobronchial Ultrasound (EBUS) was developed to help visualize structures beyond the airway wall. This includes real-time ultrasound guidance during transbronchial needle aspiration (TBNA). This improves the diagnostic yield and sensitivity as compared to conventional TBNA. While typically employed to sample mediastinal lymph nodes and masses, it has also been used to drain mediastinal cysts, sample tumors within the pulmonary vessels and detect pulmonary emboli. We present a unique case of using EBUS to drain a parabronchial loculated pleural effusion which led to distal tracheal and bronchial compression. This collection could not be accessed safely by routine ultrasound-guided thoracentesis.

CASE PRESENTATION: A 67-year-old female was referred to the Pulmonary service for progressive dyspnea. She had a history of Stage IV ovarian cancer and previously underwent an extensive debulking surgery followed by multiple lines of chemotherapy. Despite this, she developed progression of her disease with metastases to her lungs and pleura. For malignant pleural effusion, she had a right indwelling pleural catheter placed with daily drainage of approximately 200cc. However, she developed progressive respiratory insufficiency. A CT scan revealed a multiloculated right pleural effusion including a large subcarinal fluid collection leading to obstruction of the distal trachea and multiple pleural based metastases leading to extrinsic compression of the bronchus intermedius . Flexible bronchoscopy confirmed these findings. Convex EBUS was utilized to localize the subcarinal fluid collection via the right mainstem bronchus and assist with the fluid drainage; 135cc was successfully drained with subsequent improvement in distal tracheal caliber. A self-expanding metallic stent was then placed in the bronchus intermedius. The patient had significant improvement in her dyspnea following the procedure.

DISCUSSION: EBUS-TBNA is valuable as a minimally-invasive and low-risk procedure for the diagnosis of mediastinal and hilar lesions. It is increasingly being used for novel purposes, such as drainage of mediastinal cysts, sampling of tumors invading pulmonary vessels and detecting pulmonary emboli.

CONCLUSIONS: We propose that EBUS-guided thoracentesis can be successfully employed for the drainage of loculated pleural fluid that might not otherwise be accessible by conventional methods of drainage. Such drainage can be safely performed for diagnostic and therapeutic intent.

Reference #1: Nakajima T, Kazuhiro Y, Kiyosh Si, Fujisawa T. Endobronchial ultrasound-guided transbronchial needle aspiration for the treatment of central airway stenosis caused by a mediastinal cyst. Eur J Cardiothorac Surg 2007;32:538-40.

Reference #2: Swartz MA, Gillespie, CT. Pulmonary Emboli Detected by Endobronchial Ultrasound. Am J Respir Crit Care Med 2011;183:1569.

Reference #3: MacEachern P, Dang B, Stather D, Tremblay A. Tumor Invasion Into Pulmonary Vessels Viewed by Endobronchial Ultrasound. J Bronchol 2008;15:206-7.

DISCLOSURE: The following authors have nothing to disclose: Preethi Rajan, Satish Kalanjeri, Mohit Chawla

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):30A. doi:10.1378/chest.1701570

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: While relatively common in the skeletal system in general, cartilaginous tumors are almost never seen originating from the trachea. Here we report a rare case of a tracheal chondroma presenting with hemoptysis.

CASE PRESENTATION: Patient is an 85 year-old man with medical history significant only for a 20 pack-year smoking history who presented to an outside facility complaining of a single episode of hemoptysis not associated with dyspnea. Chest CT revealed a 1cm anterior tracheal wall mass without any parenchymal lung disease or lymphadenopathy. Bronchoscopy was performed in the outside facility which showed a polypoid vascular lesion. Brushings and forceps biopsies were nondiagnostic so he was referred to our interventional pulmonology clinic. Patient denied any further hemoptysis. There was no stridor on exam. Repeat bronchoscopy at our institution confirmed the presence of a polypoid white lesion originating from the anterior tracheal wall measuring 1.3 x1.0 x0.7cm and obstructing about 20% of the mid trachea. The lesion was successfully debulked from the base with biopsy forceps. On gross examination, the lesion was a tooth-like structure in shape and consistency with a vascular base. Surgical pathology revealed chondroma with atypia. Due to the potential of malignant transformation, repeat bronchoscopy and cautery of the involved mucosa were performed, and follow-up and repeat bronchoscopy in 6 months are planned.

DISCUSSION: Chrondromas are benign cartilaginous tumors generally arising from bone or synovial tissue. When associated with the airway they are almost always laryngeal in origin; chrondromas of the trachea such as presented here have been reported fewer than two dozen times in the literature 1. The differential of a cartilaginous tumor also includes the benign hamartoma, tracheopathia osteoplastica, and the malignant chondrosarcoma. Distinguishing among the cartilaginous tumors can be difficult given the overlap of histologic features, and some have even recommended classifying chondromas and chondrosarcomas as a single entity 2. Surgery remains the treatment of choice for tracheal cartilaginous tumors given the potential for malignant transformation 3, however endoscopic resection and thermal therapy is a reasonable option in an elderly patient such as ours.

CONCLUSIONS: Tracheal chondroma is a rare finding, however along with other tracheal tumors must be considered in patients presenting with hemoptysis. Surgical resection must be considered due to the possibility of malignant transformation.

Reference #1: Milisavljevic, D et al. Stridor as initial clinical presentation of tracheal chondroma. Acta Oto Esp 2011. 62(2):164-166

Reference #2: Umezu, H et al. Tracheal chondrosarcoma. Gen Thorac Cardiovasc Surg 2008; 56:199-202

Reference #3: Rea, F et al. Extended tracheal resection for chondroma. Lung Cancer 2007. 55:233-236

DISCLOSURE: The following authors have nothing to disclose: Christopher Vaughan, Ray Shepherd, Samira Shojaee

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):31A. doi:10.1378/chest.1703126

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: Ichthyosis refers to a wide range of keratinizing disorders with different etiologies. Scaling of the skin and thickening of the cornified layer characterize this condition. The two most common forms of ichthyosis, autosomal dominant ichthyosis and X-linked recessive ichthyosis, occur at frequencies of about 1/300 and 1/2500, respectively. A more heterogeneous and rare group of patients also have non-cutaneous symptoms affecting the central nervous system, immune system, skeleton or other non-cutaneous tissues. We present a case of severe tracheobronchial inflammation and stenosis in a patient with congenital ichthyosis.

CASE PRESENTATION: A 25-year-old white male with history of GERD, bronchiectasis, recurrent pneumonias and congenital ichthyosis was referred to our clinic for management of chronic productive cough. His extensive evaluation was non significant and his chest CT scan revealed mild bilateral bronchiectasis that had not changed over many years. He complained of worsening chronic productive cough with moderate amounts of yellowish mucoid sputum and occasional scant amounts of blood. After multiple failures in treatment, flexible bronchoscopy was planned to rule out atypical infections and intraluminal pathology. It was remarkable for an edematous larynx, significant inflammation of the tracheobronchial tree with significant bronchial stenosis at multiple segmental and subsegmental bronchi bilaterally. Trachea and carina forceps biopsy was performed which showed chronic inflammation of the mucosa and lamina propia. Focal areas of squamous metaplasia were identified too. In a subsequent bronchoscopy, balloon dilation was performed in multiple bronchial segments. Immediately following balloon dilation, airway diameter was visibly increased in all segments.

DISCUSSION: This case demonstrates a unique presentation of an adult patient with a diagnosis of congenital ichthyosis vulgaris involving the airways. The extensive airway involvement leads to mucosal inflammation, stenosis and partial obstruction, which most likely are responsible for this patient’s symptoms. Congenital ichthyosis in its most severe presentations has been associated with pulmonary complications in neonates and children. Neonatal asphyxia/ARDS and pneumonias are the most common respiratory complications at early age. Postmortem examination has revealed keratin debris filling the bronchial tree and alveoli 1. This has not been reported in the adult population.

CONCLUSIONS: Tracheobronchial inflammation and stenosis with Ichthyosis vulgaris, is not reported in the literature. Bronchoscopy and balloon dilation may play a roll in the management of airway stenosis in this setting.

Reference #1: Khnykin D, Ronnevig J, et al. Ichthyosis Prematurity Syndrome: Clinical Evaluation of 17 Families with a Rare Disorder of lipid metabolism. J Am Acad Dermatol 2012; 66 (4): 606-16

DISCLOSURE: The following authors have nothing to disclose: Harry Nima-Zegarra, Ray Shepherd, Samira Shojaee

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):32A. doi:10.1378/chest.1704773

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: Mycobacterium Avium Complex (MAC) is an ubiquitous bacteria known to cause lung disease in immunosuppressed individuals. Pulmonary involvement can range from asymptomatic colonization to diffuse parenchymal disease and cavitary lesions. We present the case of an AIDS patient recently started on antiretroviral therapy that developed a large polypoid endobronchial mass caused by MAC infection.

CASE PRESENTATION: A 38 year old African American female presented to the hospital with one month history of progressive shortness of breath, non productive cough and recent onset hemoptysis. She has a four year history of HIV disease and previous intermittent exposure to antiretrovirals, with poor compliance. Her symptoms developed three weeks after starting therapy with raltegravir, efavirenz, emtricitabine, tenofovir as well as MAC prophylaxis with azythromycin. Her CD4 count at presentation was 31 cells/mcL compared to 2 cells/mcL six weeks earlier. Her initial chest radiograph showed patchy multilobular densities in the right lung. Chest CT showed a large right paratracheal mass extending into the lower trachea and right mainstem with infiltrates in the right upper and middle lobes. Bronchoscopy revealed a right sided tracheal polypoid mass extending to the main carina. Forceps biopsy was performed. The pathology report showed granulation-like tissue with abundant macrophages that contained numerous acid-fast bacilli and no evidence of malignancy. The large number of bacilli within macrophages suggested infection by MAC, which was confirmed by growth on bronchoalveolar lavage sample. She was started on combination therapy with ethambutol, azithromycin and levofloxacin. A follow-up chest CT, three weeks after, revealed marked decrease in the endotracheal mass. At four weeks after discharge patient reported no shortness of breath, occasional cough and no hemoptysis.

DISCUSSION: Initiation of HAART induces immune reconstitution that is typically uneventful. We believe our patient developed immune reconstitution syndrome in response to MAC infection that was asymptomatic prior to HAART. Primary prophylaxis for MAC at the time HAART was initiated did not prevent the pulmonary manifestations. Her favorable outcome likely reflects further immune reconstitution as well as antibiotics.

CONCLUSIONS: Tumor-like endobronchial masses due to MAC can develop as part of immune reconstitution even with macrolide prophylaxis. Onset of respiratory symptoms and pulmonary infiltrates within 2 to 4 weeks of initiation of antiretroviral therapy should prompt evaluation for mycobacterial disease.

Reference #1: Peter Phillips et al. Nontuberculous Mycobacterial Immune Reconstitution Syndrome in HIV-Infected Patients: Spectrum of Disease and Long-Term Follow-Up. Clinical Infectious Diseases 2005; 41:1483-97

Reference #2: Kalayjian R C et al. Pulmonary disease due to infection by Mycobacterium avium complex in patients with AIDS. Clin Infect Dis 1995; 20: 1186-1194.

DISCLOSURE: The following authors have nothing to disclose: Sebastian Circo, Thomas Dillard, WIlliam Davis

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):33A. doi:10.1378/chest.1703324

SESSION TITLE: Bronchology Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM

INTRODUCTION: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disorder that is often misdiagnosed as asthma and the diagnosis is usually delayed.

CASE PRESENTATION: A 23-year-old female presented to clinic with six months of progressive wheezing, cough, and dyspnea. She was diagnosed with asthma by a general practitioner. Her symptoms did not respond to montelukast, inhaled fluticasone/salmeterol, and nebulized ipratropium/albuterol. She did not smoke. Physical exam was notable for tachycardia and bilateral expiratory wheezing. Laboratory data was normal. Post bronchodilator pulmonary function testing revealed FEV1 17%, FVC 21%, FEV1/FVC 53% and DLCO 61%. High resolution CT (HRCT) showed bilateral nodules, ground glass opacities, mosaic attenuation, bronchiectasis and air trapping. She underwent bronchoscopy with biopsy disclosing aggregates of hyperplastic primitive small blue cells adjacent to ciliated respiratory epithelium. She improved with systemic corticosteroids.

DISCUSSION: DIPNECH is exceedingly rare. Although, first recognized in the 1950s, fewer than 50 cases have been described. It is characterized by a generalized proliferation of scattered single cells, small nodules and/or linear proliferations of pulmonary neuroendocrine cells. DIPNECH is considered a precursor to carcinoid tumor/tumorlets. There is female predominance. It is seen most often in non-smokers. It primarily affects those in their 50s and 60s. Patients can be asymptomatic or have progressive cough and dyspnea. Diagnosis is based upon obstructive or mixed pattern on spirometry , progressive fibrosis and neuroendocrine cell hyperplasia on biopsy, plus or minus HRCT with mosaic attenuation, nodular bronchial wall thickening, bronchiectasis or mucous plugging. Little is known regarding management of DIPNECH. Some treatment strategies include systemic and inhaled corticosteroids, bronchodilators, and lung resection.

CONCLUSIONS: We have chronicled the youngest reported case of a rare pulmonary entity. It should be included in the differential for obstructive lung disease which fails to respond to conventional therapy. The diagnosis is multi-faceted. The goals of treatment are symptom relief and improved quality of life.

Reference #1: Nassar AA, Jaroszewski DE, Helmers RA, Colby TV, Patel BM, Mookadam F. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia a systemic overview. Am J Respir Crit Care Med 2011; 184:8-16.

DISCLOSURE: The following authors have nothing to disclose: Angel Brown, Michael Wells

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):34A. doi:10.1378/chest.1701367

SESSION TITLE: Bronchology Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: Persistent air leaks after pneumothorax are frequently encountered in patients with structural lung disease. For individuals with advanced medical comorbidities, treatment options are limited due to elevated risk associated with general anesthesia and surgical intervention. Interventions that involve pleurodesis have diminished efficacy in the setting of a compromised inflammatory response. One-way endobronchial valves have been effective for persistent post-operative air leaks with the advantage of a minimally-invasive approach. Typically, the valves are removed a few weeks after insertion and resolution of the air leak. However, in patients with underlying structural disease, a pneumothorax often returns, leading to repetitive hospitalizations and multiple procedures. Here we report the long-term placement of valves as destination therapy for the purpose of preventing such consequences.

CASE PRESENTATION: A 69 year-old man with acute myeloid leukemia refractory to several lines of chemotherapy and severe COPD was diagnosed with a right secondary spontaneous pneumothorax requiring chest tube placement. Five days later he continued to have a significant continuous air leak. CT-chest demonstrated apical bullae and superimposed fungal pneumonia. The interventional pulmonology and thoracic surgery team considered a number of therapeutic options including pleurodesis, video-assisted thoracic surgery with bullectomy, and apical pleurectomy all determined to be high-risk due to his compromised hematologic parameters, wound healing, and infection. Instead, we performed bronchoscopy and three endobronchial valves (IBV Valve®, Spiration) were placed into the right upper lobe apical sub-segments. The air leak promptly resolved and his chest tube was removed. Two months later, the valves were removed uneventfully, following the product's intended use guideline. Within three weeks he developed another right pneumothorax and persistent air leak. Valves were replaced in the right upper lobe apical sub-segments with the intent to remain as destination therapy. He has had no further pneumothoraces or complications related to the valves.

DISCUSSION: Endobronchial one-way valves are indicated for prolonged post-operative air leaks and removal within six weeks is recommended. However, in patients with structural lung disease and complex comorbidities that prohibit definitive intervention, recurrent pneumothoraces with persistent air leaks are likely. Such events are potentially life threatening and a source of morbidity requiring hospitalizations and uncomfortable procedures. Valves as destination therapy in these patients appears to be a safe and well-tolerated option.

CONCLUSIONS: In certain high-risk individuals with persistent air leaks after pneumothorax, one-way endobronchial valve placement as destination therapy may be a reasonable management strategy.

Reference #1: Travaline J et al. Treatment of pulmonary air leaks using endobronchial valves. CHEST 2009;136;355-60

DISCLOSURE: Jennifer Toth: Other: Educational consultants and clinical advisory board to Spiration, an Olympus subsidiary. Michael Reed: Other: Educational consultants and clinical advisory board to Spiration, an Olympus subsidiary. The following authors have nothing to disclose: Umar Osman, Christopher Gilbert

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):35A. doi:10.1378/chest.1702763

SESSION TITLE: Bronchology Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: We report the novel use of an Amplatzer Vascular Plug (AVP) in combination with a liquid embolic agent (Onyx®) to seal a chronic BPF.

CASE PRESENTATION: A 66 year old male with a history of adenocarcinoma of the right lung post-pneumonectomy in 2008 and subsequent empyema and BPF presented for BPF endobronchial closure in 2009. Multiple attempts were unsuccessful culminating in an Eloesser flap in 2010. In 2012 the BPF had healed and surgical closure of the flap was performed without complications. Six months later the patient experienced recurrent bronchorrhea with imaging confirming a recurrent BPF. After a multidisciplinary review; given high surgical risk, the decision was made to reattempt endobronchial closure of the BPF. Under rigid bronchoscopy, the right main stem bronchial stump was intubated allowing for passage of a microcatheter to be coiled within the distal stump. Under bronchoscopic and fluoroscopic guidance, an 18mm AVP II® was deployed in the bronchial stump. The stump was then embolized with Onyx-34® liquid embolic through the previously placed microcatheter with care to avoid Onyx® extension above the plug. The patient tolerated the procedure well and was discharged on postoperative day 1 with a marked decrease in respiratory symptoms.

DISCUSSION: The first successful endobronchial management of a BPF using tissue glue and a lead shot was reported in 1977. Since then, many techniques have been employed with varying degrees of success. In our case, endobronchial therapies including cyanoacrylate and SIS® plugs had previously failed resulting in the decision to use an AVP and liquid embolic agent. Onyx® is a non-adhesive liquid embolic agent comprised of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide. These qualities seem to make it an excellent medium for both affixing the AVP as well as filling of the BPF.

CONCLUSIONS: We conclude that AVP when combined with Onyx® is an effective technique to seal BPF. This technique may offer an alternative to patients who are otherwise poor surgical candidates.

Reference #1: Reference: Fruchter, O., et al., Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug. Eur J Cardiothorac Surg, 2012. 41(1): p. 46-9.

Reference #2: Spiliopoulos, S., et al., Successful exclusion of a large bronchopleural fistula using an Amplatzer II vascular plug and glue embolization. Acta Radiol, 2012. 53(4): p. 406-9.

DISCLOSURE: The following authors have nothing to disclose: Vikas Pathak, Lonny Yarmus, Mark Lessne, Kelvin Hong, Malcolm Brock, David Feller-Kopman, Jason Akulian

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Chest. 2013;144(4_MeetingAbstracts):36A. doi:10.1378/chest.1704809

SESSION TITLE: Bronchology Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: Stenting for tracheoesophageal or bronchoesophageal fistulae is usually palliative in the setting of malignancy. Although tubular stents may be placed in the trachea or bronchi, and Y-stents at the main carina, the use of Y-stents in the secondary carina has not previously been described for this indication.

CASE PRESENTATION: A 64 year old woman with a history of metastatic renal cell carcinoma, diffuse large B-cell lymphoma, and other medical comorbidities previously had a partially covered esophageal stent placed for dysphagia due to a mid-esophageal stricture. She subsequently presented with uncontrollable cough, recurrent pneumonia, and a severely impaired quality of life due to an inability to tolerate oral intake. Evaluation demonstrated a bronchoesophageal fistula in the right mainstem bronchus (Figure 1). Bronchoscopy was performed demonstrating a defect along the right mainstem bronchus that extended to within 5 mm of the right hilum distally and 8 mm of the trachea proximally. Given that a tubular stent would not adequately cover the defect due to its proximity to the right hilum, and due to the high chance of migration in this area, a silicone Y-stent was configured. The 14 x 10 x 10 mm diameter stent was sized to include a 5 mm limb extending into the right upper lobe bronchus, a 16 mm limb in the bronchus intermedius and a 25 mm limb in the right mainstem bronchus. This completely covered the fistulous tract while maintaining patency of the bronchi and minimizing the chances of migration and granulation tissue formation.

DISCUSSION: Respiratory-digestive fistulae may result directly from cancer erosion, from treatment of malignancy with radiation or chemotherapy, and, as shown in this case, as a complication of primary esophageal stenting. In a study of 264 patients with malignant fistulae, 44% were present in the right mainstem bronchus.1 When these fistulae involve the right hilum, tubular stenting will not satisfactorily cover the defect. As such, the only feasible option is the use of a Y-stent at the secondary carina. Although Y-stents are placed less commonly, recent publications demonstrate feasibility.2

CONCLUSIONS: The treatment of tracheobronchial fistulae is complex, particularly in the setting of malignancy in which surgical repair is not typically feasible. When confronted with fistulae that involve the secondary carina, consideration should be given to Y-stent placement. Although described for post-transplant stenosis and malignancy, this is the first case to our knowledge of its utility for bronchoesophageal fistula.

Reference #1: Rodriguez, AN and Diaz-Jimenez, J.P. Malignant respiratory-digestive fistulas. Current Opinion in Pulmonary Medicine, 2010. 16:329-88.

Reference #2: Lee HJ, Puchalski J, et al. Secondary carina Y-stent placement for post-lung-transplant bronchial stenosis. J Bronchology Interv Pulmonol. 2012 Apr;19(2):109-14.

DISCLOSURE: The following authors have nothing to disclose: Christopher Erb, Margaret Pisani, Jonathan Puchalski

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):37A. doi:10.1378/chest.1704593

SESSION TITLE: Bronchology Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: Probe-based confocal laser endomicroscopy (pCLE) allows the bronchoscopist to visualize microscopic tissue architecture in vivo. Spray cryotherapy is an endoscopic treatment modality that, until recently, has only been approved for use in the gastrointestinal tract but has been demonstrated to be effective in the treatment of endobronchial malignancy. However, a new low-flow spray cryotherapy system has been approved for use in the tracheobronchial tree. We discuss the use of pCLE to guide the endobronchial application of low-flow spray cryotherapy.

CASE PRESENTATION: An 87 year old female with a significant smoking history was referred to pulmonary clinic for evaluation of exertional dyspnea and non-resolving RML infiltrate. Spirometry was consistent with severe obstruction (FEV1 47% predicted) and imaging revealed a enlarging, infiltrative mass extending peripherally from the right hilum into middle and lower lobes with small ipsilateral pleural effusion and mediastinal adenopathy. Diagnostic thoracentesis identified small cell carcinoma; subsequent PET-CT and CT brain identified metastases in the left adrenal, right breast, and brain. Videobronchoscopy demonstrated a mixed infiltrating and partially obstructing tumor in the right lower lobe. Further examination with pCLE identified abnormal tissue architecture that extended proximally beyond the visual abnormality. Low-flow spray cryotherapy was then applied to all areas of visual and endomicroscopic abnormality. Subsequent bronchoscopic examination demonstrated regression of the tumor.

DISCUSSION: Recent technological advances have greatly increased the variety of tools available for endobronchial treatment of malignancy. Spray cryotherapy has been demonstrated to be effective in the treatment of lung cancer, but there were concerns about significant rates of complications. The recent development of a low-flow cryotherapy system may alleviate these concerns. The concomitant use of pCLE may be able to identify microscopic extension of endobronchial malignancy not apparent on white light bronchoscopy and expand the target area for spray cryotherapy and other therapeutic modalities.

CONCLUSIONS: Use of pCLE to inspect for microscopic margins of endobronchial lesions in conjunction with low flow spray cryotherapy improves therapeutic coverage of malignant endoluminal disease and allows for earlier treatment of potential airway obstruction.

Reference #1: Thiberville L, Salaün M, Lachkar S, et al. Confocal Fluorescence Endomicroscopy of the Human Airways. Proc Am Thorac Soc 2009; 6:444-449.

Reference #2: Lee SH, Choi WJ, Sung SW, et al. Endoscopic cryotherapy of lung and bronchial tumors: a systematic review. Korean J Intern Med 2011; 26:137-144.

Reference #3: Shibuya K, Fujiwara T, Yasufuku K, et al. In vivo microscopic imaging an endo-cytoscopy system. Lung Cancer 2011; 72:184-190.

DISCLOSURE: The following authors have nothing to disclose: David Hostler, Scott Parrish, Robert Browning

No Product/Research Disclosure Information

Topics: lasers , cryotherapy
Chest. 2013;144(4_MeetingAbstracts):38A. doi:10.1378/chest.1689732

SESSION TITLE: Airway Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Combined pulmonary fibrosis and emphysema (CPFE) is a syndrome that is characterised by centrilobular and/or paraseptal emphysemas in upper lung zones associated with pulmonary fibrosis in lower lobes. In this retrospective cohort study: demographics, clinical and radiological characteristics and pulmonary function tests of patients with CPFE were reviewed. Patient survival were also analysed. Medical records and high resolution computed tomographic (HRCT) images of 10 patients with CPFE were reviewed through multidisciplinary discussion including pulmonologists and a radiologist. Survival was calculated from date of first assessment to the date of death, or from date of first assessment to the date of review..

CASE PRESENTATION: The mean age is 65 years, and all of the patients are male. All patients had histories of smoking (mean: 41 pack-years). One patient had 30 pack year history of smoking associated with the occupational exposure of lead and sulfur gas during 8 years. Mean FVC, FEV1, FEV1/FVC and DLCO were 64%, 66%, 81%, and %30, respectively. The HRCT images showed that, 9 patients had paraseptal emphysema and bullous formation, 5 had centrilobular emphysema, 8 had honeycombing, 10 had reticulation, traction bronchiectasis, and ground-glass opacity, 6 had bronchial distortion. The mean diameter of the main pulmonary artery was 32.6 mm. In one case, a new nodular lesion of 1.2 cm, which is not exist a year ago, was found Eight patients required supplemental oxygen therapy during their follow-up, and 2 patients died. Two patients developed pneumothorax and pleuredesis was performed in one of them because of recurrent pneumothorax. Deep venous thrombosis occured in a patient. The median survival of this cohort is 3.6 years.

DISCUSSION: The CPFE syndrome typically occurs in current or ex-smoker male gender. The subset of patients (predominantly male) exposed to cigarette smoking may be vulnerable to developing the typically extensive emphysema and pulmonary fibrosis. The physiologic outcomes of CPFE syndrome include normal or subnormal expiratory flow rates and lung volumes in the setting of extensive radiologic evidence and severely impaired DLCO. Patients with CPFE have a high prevalences of pulmonary hypertansion and lung cancer. The main pulmonary artery diameter of 29 mm or larger on computed tomography scan has a sensitivity of 69% and a specificity of 100% for predicting pulmonary hypertension. In this cohort, main pulmonary artery diameter is greater than 29 mm in all patients. This suggests increased pressures in the pulmonary system of all patients.

CONCLUSIONS: Characteristic epidemiologic, clinical and radiologic findings in the CPFE syndrome include smoking history, male predominance, hypoxemia, normal or subnormal sprometric values despite extensive radiologic involvement, and marked impairement of gas exchange. In patients with dyspnea, an isolated reduction in DLCO is extremely rare and one of the causes is CPFE

Reference #1: Jankowich M, Rounds S. Combined pulmonary fibrosis and emphysema syndrome. Chest 2012; 141: 222-231.

Reference #2: Heathcote KL, Cockcroft DW, Fladeland DA, Fenton ME. Normal expiratory flow rate and lung volumes in patients with combined emphysema and interstitial lung disease: a case series and literature review. Can Respir J. 2011; 18:e73-e76

Reference #3: Portillo K, Morera J. Combined pulmonary fibrosis and emphysema syndrome: a new phenotype within the spectrum of smoking-related interstitial lung disease. Pulmonary Medicine 2012 as doi. 10.1155/2012/867870

DISCLOSURE: The following authors have nothing to disclose: Serir Özkan, Rahime Kayali, Recep Savas, Onur Fevzi Erer, Celalattin Yilmaz

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):39A. doi:10.1378/chest.1700364

SESSION TITLE: Airway Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary hypertension (PH) in COPD shows mild to moderate elevation in pulmonary artery pressure (PAP). However, a small subgroup of may present with “out of proportion” PH. We report a case of severe PH secondary to COPD, with PAP returning to near normal values after Inhaled Corticosteroid/Long Acting B-agonist (ICS/LABA) treatment.

CASE PRESENTATION: RO is a 36yo male miner/fisherman originally from Surigao - consulted our clinic due to hemoptysis. There was history of pulmonary tuberculosis; he was a previous 60 pack year smoker. Symptoms of exertional dyspnea, pleuritic chest pain and palpitations started 15 months prior to consult. During this time there was also note of icteric sclerae. Expectoration of pink frothy sputum was noted about thirteen months prior to consult. Initial 2D Echocardiography (2DE) revealed ejection fraction (EF) of 84; PAP 42mmHg; dilated right ventricle (RV), right atrium (RA), main pulmonary artery, severe PH; TEE confirmed PH, no congenital heart defect noted. Patient had stable vital signs, BMI 22.96kg/m2; room air SaO2 90%; unremarkable pulmonary and cardiac findings; no edema, cyanosis nor clubbing. Spirometry revealed moderate obstructive ventilatory defect (FEV1 59% predicted), no significant bronchodilator response; baseline 6-minute walk test (6MWT) 395 m. Rectal imprint negative for schistosoma eggs. At this point, COPD as the possible etiology of PH was confirmed. Three months post-treatment with ICS/LABA, there was noted improved symptoms; repeat 6MWT increased to 498.5 m; repeat 2DE after 6 months - EF 86; PAP of 21.62mmHg.

DISCUSSION: A small subgroup of COPD patients (<5%) have “out-of-proportion” PH - defined by PAP >35 - 40 mmHg and mild to moderate airflow limitation. Doppler echocardiography is best to screen PH; with right heart catheterization (RHC) as the gold standard. However, there are no evidence-based studies demonstrating clinical value of RHC among COPD patients. Recent studies hypothesize that systemic inflammation may play a role in the pathophysiology of PH in COPD. LTOT remains the cornerstone of treatment; optimal ICS/LABA treatment cannot be overemphasized given the potential role of inflammation.

CONCLUSIONS: Our patient presented with “out - of - proportion” PH, treated with ICS/LABA. Optimal LTOT improves and stabilizes PH; no reports reverting PAP to near normal values were retrieved as of this writing. Our case has demonstrated that PAP may return to near normal values with optimal ICS/LABA treatment.

Reference #1: Weitzenblum, E., FCCP and Chaouat, A., MD , “Severe Pulmonary Hypertensio in COPD: Is It a Distinct Disease”. CHEST 2005; 127; 1480 - 1482.

Reference #2: Minai, O., et al., “Pulmonary Hypertension in COPD: Epidemiology, Significance, and Management: Pulmonary Vascular Disease: The Global Perspective”. CHEST 2010; 137; 39S - 51S.

Reference #3: Preston, I., “Pulmonary Hypertension in Chronic Obstructive Pulmonary Disease: Diagnosis and Management”. Advances in Pulmonary Hypertension 2009; 8: 3.

DISCLOSURE: The following authors have nothing to disclose: Reinalyn Cartago, Lenora Fernandez

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Chest. 2013;144(4_MeetingAbstracts):40A. doi:10.1378/chest.1701020

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Although foreign body (FB) aspiration is frequently suspected in children with acute or recurrent respiratory symptoms, it is rarely considered in adults with sub-acute or chronic respiratory symptoms, unless a clear history of an aspiration event is obtained. Aspiration of large foreign bodies or food particles can obstruct the trachea to cause immediate asphyxiation and death. However smaller foreign bodies pass distally after aspiration and cause bronchial obstruction. Here we report a case of incidentally detected FB, in an elderly presenting with cough and hemoptysis.

CASE PRESENTATION: A 70 year old non smoker, teetotaller businessman from West Bengal came to the respiratory outpatient with complaints of cough and left side chest pain since 3 months and one episode of moderate hemoptysis 2 month ago. He denied weight loss or any other constitutional symptoms. He was known diabetic and hypertensive on oral medications. Auscultation revealed coarse crackles in left base. Lab investigations were normal except for an elevated ESR of 49 mm/hr. CXR done showed bronchiectatic changes in left lower lobe (LLL). CT chest showed bronchiectasis in LLL, a small area of calcified spot was seen near the division of LLL. On enquiring the patient about history of FB aspiration, he denied any such episodes. Suspecting a FB aspiration, bronchoscopic examination was done which showed a small, long, hard foreign body embedded in the lateral wall of LLL at the entrance, extending upto the opposite bronchial wall. The base was surrounded by granulation tissue and thick purulent secretions were seen distally. An attempt was made to remove FB with a forceps but as it was embedded in the bronchial wall, a small fragment could be removed. On subjecting to histopathological examination it was refractile and crystalline. He was advised for lobectomy as it was embedded in the bronchial wall and there was infected ectasis distal to it.

DISCUSSION: Foreign body aspiration in adults is more common in the setting of advanced age, underlying neurological disorder, poor dentition, alcohol consumption and sedative use where the normal laryngeal reflex which prevents aspiration is impaired. In absence of any of these, children are more prone for aspiration than adults. But our patient did not have any such predisposing factors. The clinical and radiological manifestation of FB aspiration depends on the size of the aspirated material. In our case the chest radiograph did not show any evidence of FB aspiration. Chest radiography of FB aspirations manifests with air trapping, atelectasis, bronchiectasis or pneumonia distal to the obstruction in case of smaller foreign bodies. CXR show a radio opaque FB only in 5 - 15% of the cases. Most common location being right lower lobe (RLL) (28%), 17% in LMB. In our case it was in LLL which is rare.

CONCLUSIONS: This case demonstrates the possible risk of silent aspiration of foreign bodies and in our case presenting as a persistent cough and hemoptysis probably months after aspiration. Bronchoscopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary symptoms. Time to diagnosis of foreign bodies in adults has been longer when compared to children. Occult foreign body in adults may remain undetected for years, leading to erroneous diagnosis of asthma, bronchitis or pneumonia.

Reference #1: Armstrong P, Hansell D M, Lynch D A, McAdams H P. Imaging of diseases of the chest.4th edition.2005,Elsevier Mosby:474-75.

Reference #2: Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? . Clin Chest Med. 2001;22(2):319.

Reference #3: Rahulan V, Patel M, Sy E, Menon L. Foreign body aspiration in elderly: an occult cause of chronic pulmonary symptoms and persistent infiltrates. Clin Geriatr 2003;11:41-3.

DISCLOSURE: The following authors have nothing to disclose: Amrut Sindhu Sanikop, Narasimhan Raghupathi

No Product/Research Disclosure Information

Topics: cough , hemoptysis , bronchi
Chest. 2013;144(4_MeetingAbstracts):41A. doi:10.1378/chest.1702527

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: In the stent placement for the airway stenosis under the glottis, T-tube stent is generally chosen in order to prevent migration. However, the problem is that tracheotomy is required to place the T-tube stent and it decreases the QOL of the patient.

CASE PRESENTATION: It was the case of a 74-year-old man, who was seen in our clinic because of respiratory discomfort. In the bronchoscopic examination, a polyp narrowing about 80% of the lumen under the glottis was found, and he was diagnosed as squamous cell carcinoma by biopsy. Since he refused surgery, after we performed endoscopic polypectomy, we added radiation treatment(external irradiation:60Gy, intracavitary irradiation:10Gy). For the subsequent recurrence, we repeatedly performed endoscopic tumor resection, but we became no longer able to control the enlargement of the tumor, so we decided to place a stent. Though we recommended the placement of T-tube to the patient, he refused it because of the necessity of tracheotomy. Then we tried to place a DUMON stent(φ14mm, 45cm long) in the narrowed area under the glottis and fix it to the trachea with sutures. First, we inserted two needles into the stent through the body surface of the neck. We led a loop thread from the needle in the proximal side into the stent and led the other nylon thread from the needle in the distal side into the stent. We endoscopically used forceps to pull the thread into the loop and pull it with the loop out to the body surface and ligated them on the neck.

DISCUSSION: This time’s procedure is very simple and can be easily performed by anyone once they get used to it. This procedure is easier than the traditional one in which people perform a tracheotomy on the narrowed area and insert a T-tube there, and the patient burden is also much reduced.

CONCLUSIONS: The method in which people endoscopically use sutures to fix a DUMON stent to the trachea for the airway stenosis under the glottis proved very useful because it can maintain the QOL of the patient after therapy.

Reference #1: 3

DISCLOSURE: The following authors have nothing to disclose: Hibiki Kanda, Shinichi Iwamoto, Mitsuhiro Tada, Emiko Nishikawa, Toru Kadowaki, Masahiro Kimura, Kanako Kobayashi, Toshikazu Ikeda, Shuichi Yano

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):42A. doi:10.1378/chest.1704482

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Huge bullae may compress lungs leading to ventilation decrease. Sometimes that is lethal to COPD patients with huge bullae. Conventional surgery is useful for the treatment of huge bullae. However, some patients could not endure that. Bronchial occlusion with occluder devices under bronchoscopy may be alternative to huge bullae treatment.

CASE PRESENTATION: A 64-year-old man presented with cough and sputum for 34 years, dyspnea for 5 years, exacerbation with oedema legs for 3 weeks. A chest CT demonstrated COPD features and two huge bullae. The bulla in the right upper lobe was 4X12X6cm, the bulla in the lower lobe was 12X10X10cm. Functional lung in the middle and lower lobes were almost not seen. Except for routine therapies on AECOPD and respiratory failure, closed drainage of the bulla in the right lower lobe was down. The bulla became much smaller rapidly and dyspnea relieved, but air leakage persisted. 300ml autoblood were injected into the bulla on the 12th day after drainage trying to stop air leakage, but it failed. On the thirtieth day, an occluder device made of nickel titanium alloy and polytetrafluoroethylene membrane was inserted to the bronchus of lateral basal segment in right lower lobe. Eight days later, air leakage stoped and the drainage was removed. Since then, the patient developed exacerbation 2-3 times every year, routine therapies of AECOPD were carried out repeatedly. Chest CT at 1 and 2 years after occluder device insertion showed atelectasis of the lateral basal segment, the middle lobe and other basal segment expanded. The patient died of severe pneumonia of both lower lobes 28 months later. The last CT showed bronchiectasis in the post basal segment of rigte lower lobe.

DISCUSSION: Bullae are common in COPD patients. Small bullae have less impact on pulmonary function. Huge bullae were harmful and sometimes may be lethal to the patients. Conventional surgery is not tolerated by all patients with huge bullae. Our report suggested that bronchial occlusion combined with closed drainage and autoblood injection into bullae might be a useful strategy. But the affection of occluder divices to the drainage ot adjacent bronchi should be considered.

CONCLUSIONS: Bonchial occlusion combined with closed drainage and autoblood injection into bullae might be an alternative for the treatment of huge bullae. But the affection of occluder divices to adjacent bronchi should be considered.

Reference #1: Gunnarsson SI, Johannesson KB, Gudjonsdottir M, et al. Incidence and outcomes of surgical resection for giant pulmonary bullae--a population-based study. Scand J Surg. 2012;101(3):166-9.

DISCLOSURE: Jianlinhu Hu: University grant monies: employment

This report was granted by clinic innovation fund of the military medical university /2009XLC14

Chest. 2013;144(4_MeetingAbstracts):43A. doi:10.1378/chest.1703774

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchopleural fistula (BPF) is a complication, mostly encountered after lung surgery and invasive diagnostic procedures but it’s rarely seen due to tuberculosis. The standard methods of treating persistent air leak include continued chest tube suction, Heimlich valves or surgical repair. In patients not suitable for surgery due to extensive inflamatory process, bronchoscopic approaches may bring to a successful conclusion. This is the first description of the use of a removable, one-way, endobronchial valve(EBV) to treat BPFs with non-resolving spontaneous pneumothorax complicating extensive cavitary pulmonary tuberculosis(PTB).

CASE PRESENTATION: 21-year-old- male patient was admitted with complaints of cough and sputum for 10 days. Chest X ray showed cavitary lesions with reticulonodular changes in the right upper lung field. Sputum smear was positive for acid fast bacilli. Thus, the patient was diagnosed as PTB and antituberculosis therapy was started. Three days later, the patient developed acute dyspnea and right chest pain. Chest X ray demonstrated a right hydropneumothorax. A chest tube drainage was applied on the right side. Even under negative pressure, chets tube drainage did not work and radiological controls showed no resolution of hydropneumothorax. Because of the early period of PTB and intense inflammation of lung parenchyma, surgical treatment was not considered at this stage and open drainage was performed. Thorax CT scans revealed partly collapse of upper lobe and completely collapse of lower lobe. After possible places of air leakage was observed, it was planned to insert EBVs in related segments of upper lobe. Occlusion of apical and posterior segments was attempted using the balloon catheter passed through a bronchoscope and the air leak stopped immediately. After that, two EBVs were placed in the apical and one was placed in the posterior-segment bronchi. After a while, air leak stopped and, thorax CT showed complete resolution of hydropneumothorax and almost complete regression of cavities after 3 months.

DISCUSSION: There are successful case reports using EBVs for spontaneous pneumothorax and prolonged air leak due to lung surgery, empyhema, malignancy and thoracic trauma1-3. To our knowledge, this is the first case that used a one-way endobronchial valve to manage severe air leak due to extensive PTB.

CONCLUSIONS: One-way endobronchial valve replacement for a bronchopleural fistula may be the initial approach before surgical procedures in critically ill patient.

Reference #1: Feller-Kopman D, Bechara R, Garland R, et al. Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest 2006; 130:273-275

Reference #2: Anile M, Venuta F, De Giacomo T, et al. Treatment of persistent air leakage with endobronchial one-way valves. J Thorac Cardiovasc Surg 2006; 132:711-712

Reference #3: Travaline JM, McKenna RJ, Jr., De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009; 136:355-360

DISCLOSURE: The following authors have nothing to disclose: Mehmet Aydogan, Alper Gündogan, Ergun Uçar, Hasan Çaylak, Orhan Yücel, Ergun Tozkoparan, Sedat Gürkök, Hayati Bilgiç

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):44A. doi:10.1378/chest.1703679

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheobronchopathiaosteochondroplastica is a rare disorder of unknown cause affecting the large airways.This disease has been written in case reports. However, the association with active pulmonary tuberculosis has not been reported in recent literature.

CASE PRESENTATION: Patient is E.R. a 57 yo female hypertensive, non-smoker seen at the outpatient department for 4 weeks history of non-productive cough and hoarseness. There was note of fever, weightloss and anorexia. She sought consult and was treated as a case of pnuemonia and was given several courses of antibiotics with no relief of symptoms. 1week prior to admission, there was persistence of symptoms now associated with difficulty of breathing . She notes difficulty in sleeping described as choking sensation. Pertinent physical examination,revealed stable vital signs, afebrile, BMI 22 , 98% O2 saturation at room air, there was note of basal ronchi on auscultation. Laryngoscopy showed hyperemic vocal cords with a polypoid mass on the right vocal fold impression was Chronic laryngitis Cxray showed infiltrates on the left upper lobe suggestive of tuberculosis. Ct scan showed ground glass opacities in the superior segment of both lower lobes, small nodule posterior segment of right upper lobe, fibrosis left apical lobe and narrowing of the right main stem bronchus. There were no lymphadenopathies. Neck Ct scan showed no masses, but with irregular borders on the right bronchus, with collapse of the right upper lobe Patient underwent bronchosocpy which revealed edematous vocal cords, cobble stoning with hard protruding cartilaginous structures covered with cottony exudates seen from the trachea to the right main bronchus. Bronchial washing was positive for Kliebsiella Pnuemonia. Biopsy showed fragments of degenerated epithelilal cells, necrotic debris. Cartilage and fibrin material with acute and chronic inflammatory cells consistent with ulcer bed and necrotic debris. Special AFB stain is positive for numerous acid fast bacilli consistent with Tuberculosis. She was started on INH/ RIF/PZA/EMB. Patient still had difficulty of breathing and underwent bronchosopy to remove the remaining cartilaginous material which was done using rigid bronchoscopy. Histopathology confimed the diagnosis of Tracheobronchopathiaosteochondroplastica revealing cartilage with areas of ossification. There was note of improvement of symptoms and patient continued treatment for 6 months.

DISCUSSION: Tracheobronchopathiaosteochondroplastica is a rare disorder of unknown cause affecting the large airways of adults affecting both genders. It is described a multiple osseous and cartilaginous nodules in the submucosa of the trachea and main bronchi.Presentation of such entity ranges from an asymptomatic patient to cough, hemoptysis and recurrent respiratory infections. It may cause significant airway obstruction and difficulty of intubation.Kliebsiella is frequently isolated however there is no clear relationship. Theories of its etiology includes ecchondrosis, exositosis from tracheal rings or metaplasia of submucosal and connective tissue cartialage and/ or bone tissue .

CONCLUSIONS: Tracheobronchopathiaosteochondroplastica is a rare disorder described as multiple osseous and cartilaginous nodules in the submucosa of the trachea and main bronchi. The patient presented with recurrent respiratory infection and upper airway obstruction. Biopsy revealed cartilage with ossifiction and acid fast bacilli consisitent with tuberculosis. Rigid bronchoscopy was done to remove the obstruction. The association of these two disease has not been reported in recent literature.

Reference #1: Harikrishna Doshi .J Thorac Cardiovasc Surg 2005;130:901-902 Tracheobronchopathia osteochondroplastica presenting as an isolated nodule in the right upper lobe bronchus with upper lobe collapse

DISCLOSURE: The following authors have nothing to disclose: Angelene Taleon-Parazo

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Topics: tuberculosis
Chest. 2013;144(4_MeetingAbstracts):45A. doi:10.1378/chest.1702461

SESSION TITLE: Airway Cases II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a rare, benign neoplasm of the airway caused by human papilloma virus (HPV). Adults with RRP are often immunocompromised, and lesions tend to be aggressive. Malignant transformation has been reported to occur. We report a case of RRP in an HIV positive man with upper airway obstruction and recurrent squamous cell carcinoma (SCC) of the lung.

CASE PRESENTATION: A 50 year old male former smoker with AIDS and recurrent sinonasal papillomas comes to the Emergency Department (ED) because of shortness of breath. Medical history includes: Hodgkin’s Lymphoma, treated 5 years ago, and SCC of the lung, resected one year later. Papillomas have been treated since the time of diagnosis 10 years ago, with multiple debulking procedures and interferon. In the ED, patient reported progressive dyspnea over 3 months, a productive cough with white, non-bloody sputum, and a hoarse voice. On examination, inspiratory and expiratory stridor with mildly labored respirations was noted; room air oxygen saturation was 100%. MRI of the neck revealed a large tracheal mass causing near complete obstruction. PFTs were consistent with fixed airway obstruction. The patient was intubated, and underwent surgical debulking, plus treatment with a microdebrider and C02 laser, and intralesional injection of cidofavir. The patient was extubated 1 day post op with significant improvement. Five months later, he was readmitted for recurrent tracheal papillomas, and has since required 2 additional surgical interventions, and now is diagnosed with metastatic SCC lung cancer.

DISCUSSION: RRP can be very resistant to medical and surgical treatment. This patient was refractory to medical treatment that included interferon and intralesional cidofovir. Response to Bleomycin has been reported, and was part of this patient’s Hodgkin’s disease chemotherapy, and may have been associated with slower growth during the treatment period. Mechanical debulking with surgical excision, microdebridement and C02 laser provide temporary benefit. Endobronchial stents are sometimes needed. A small percentage of patients demonstrate malignant transformation to SCC. HPV 11 and smoking are reported risk factors for this. Subtype data was not available for this patient. The HPV vaccine which targets HPV 11 offers hope in reducing the incidence of this frequently complicated disease.

CONCLUSIONS: RRP from HPV infection can be refractory to treatment and may cause upper airway obstruction. Recurrence is expected, and malignant transformation may occur, especially in immunocompromised individuals.

Reference #1: Boston, Mark et al. "Recurrent Respiratory Papillomatosis." Clinical Pulmonary Medicine 10.1 (2003): 10-16.

Reference #2: Chaturvedi, A. K., et al. "Risk of Human Papillomavirus-Associated Cancers Among Persons With AIDS." JNCI 101.16 (2009): 1120-130.

Reference #3: Yuan, Hang, et al. "Use of Reprogrammed Cells to Identify Therapy for Respiratory Papillomatosis." NEJM 367 (2012): 1220-227.

DISCLOSURE: The following authors have nothing to disclose: Rishi Mehta, Jean Anderson Eloy, Andrew Berman

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Chest. 2013;144(4_MeetingAbstracts):46A. doi:10.1378/chest.1698542

SESSION TITLE: Airway Cases II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM

INTRODUCTION: Airway stabilization for severe symptomatic tracheobronchomalacia (TBM) may be accomplished by silicone Y-stent placement. Complications of the stent may include mucus plugging and the formation of granulation tissue. We describe management of a very rare case of pulsatile, life-threatening hemoptysis originating from the distal left mainstem bronchus adjacent to the bronchial limb of a Y-stent placed for TBM.

CASE PRESENTATION: A 65 year-old female presented to the ICU with massive hemoptysis 3 months after placement of a Y-stent for symptomatic TBM in which tracheobronchoplasty was not a viable treatment option. One month prior to her hemoptysis presentation, she underwent argon plasma coagulation (APC) to ablate granulation tissue. Following intubation, the bleeding source was bronchoscopically localized to the distal left mainstem bronchus and an endobronchial blocker was placed to stabilize the patient. She urgently underwent removal of the Y stent and a pulsatile vessel was identified as the bleeding source. This vessel was visualized just beyond the bronchial limb of the Y-stent in the distal left mainstem bronchus, proximal to the left hilum. Its pulsatile nature and location suggested an arterial source. Placement of oxidized cellulose (Surgicel, Ethicon) controlled the bleeding. Using two ureteral catheters tied in tandem, a synthetic sealant (CoSeal, Baxter) was then administered endobronchially at the site of bleeding. Placement of these catheters distally in the left mainstem enabled endobronchial mixing of the sealant for direct application at the bleeding site. She had no further hemoptysis, and follow-up bronchoscopy 3 weeks later demonstrated mucosal healing.

DISCUSSION: In the few cases of hemoptysis following Y-stent placement, the proposed mechanism is either local erosion or fistula formation.1In this case of pulsatile hemoptysis due to bleeding from an arterial source, we hypothesized that the oxidized cellulose provided sufficient hemostasis and the subsequent synthetic polymer (CoSeal) reinforced the tissue for complete cessation of the bleed. Removal of the stent minimized the risk of recurrent bleeding.

CONCLUSIONS: Massive hemoptysis complicating Y stent placement is rare. In addition to minimizing ongoing injury, a combination of endobronchial oxidized cellulose and a synthetic polymer provided long-term management for this potential life-threatening problem. Potentially morbid procedures such as embolization or surgery were avoided by advanced endobronchial therapy.

Reference #1: Oki, M and Saka, H. New Dedicated Bifurcated Silicone Stent Placement for Stenosis Around the Primary Right Carina. Chest. 2013 Mar 7. doi: 10.1378/chest.12-2834.

DISCLOSURE: The following authors have nothing to disclose: Changwan Ryu, Kyle Bramley, Daniel Boffa, Margaret Pisani, Jonathan Puchalski

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Chest. 2013;144(4_MeetingAbstracts):47A. doi:10.1378/chest.1704002

SESSION TITLE: Airway Cases II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM

INTRODUCTION: Neck and chest trauma in the pediatric population resulting in tracheal rupture is a rare, life-threatening situation. Prompt diagnosis can be difficult and imaging studies may fail to recognize lesions initially. Conservative and surgical management have been described; yet there is paucity of literature emphasizing on the pediatric population.

CASE PRESENTATION: A 9-year-old female suffered a gunshot wound to right thorax with entry and exit. Upon arrival to trauma unit, she was intubated and had a right chest tube placed. Initial thorax CT scan confirmed pneumomediastinum, subcutaneous emphysema, right tension pneumothorax with right lung collapse, ipsilateral hemothorax and a severe T5 comminuted fracture. On the PICU, patient was noted with no exhaled tidal volume (Vte), flow, pressure nor capnography waveforms registered during mechanical ventilation and presence of massive airleak on chest tube, while maintaining peripheral saturation 96-99%. The endotracheal tube (ETT) was advanced into the right main stem bronchus due to suspected tracheal defect. New chest CT scan revealed right tracheal cortical discontinuity 0.5 cm AP by 1 cm long located 1 cm above the carina bifurcation. The ETT was distal to the rupture, with almost complete re-expansion of the right lung and interval improvement of previously seen pneumomediastinum. After multidisciplinary evaluation, a conservative approach was decided upon. A left double lumen tube (DLT) was used to bypass the tracheal defect and ventilate the left lung. 72 hours later, she had interval progression of pneumomediastinum and subcutaneous emphysema. Bilateral bronchial intubation was decided upon, but in order to fit two ETT’s by the vocal cords of a pediatric patient, and due to the length of ETT required to bypass the lesion safe and effectively; a customized extra-long tube was created using two 4.5 mm ID ETT’s for each bronchus. Right bronchial intubation was performed and left endobronchial tube was inserted using a stylet. Each cuff was gently inflated and correct positioning confirmed by fiberoptic visualization. The ongoing air leak resolved and the patient was able to receive long-term ventilatory support with bilateral bronchial tubes.

DISCUSSION: Surgical repair of tracheobronchial injuries has been regarded as treatment of choice; yet successful conservative management has been achieved and should be considered as a starting point when appropriate. In our case, the surgery and anesthesiology teams opted for a conservative approach. The size of the lesion was small, there was no associated esophageal injury, and the defect was deemed bridgeable by an artificial airway.

CONCLUSIONS: Although an initial attempt to isolate the defect with a DLT proved ineffective, bilateral bronchial intubation was successful. The fabricated tubes proved to be a reliable, safe and stable alternative for proper bronchial intubation on a pediatric patient.

Reference #1: carlos.ocasio@upr.edu

DISCLOSURE: The following authors have nothing to disclose: Carlos Ocasio-López, María Sánchez, Miguel Marrero, Ricardo García-De Jesús

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Chest. 2013;144(4_MeetingAbstracts):48A. doi:10.1378/chest.1690364

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Ciliopathic diseases are associated with a broad spectrum of physical findings including bronchiectasis, situs inversus, postaxial polydactyly, and retinal abnormalities. Recent literature classifies Bardet-Biedl Syndrome (BBS) as a ciliopathy. BBS is a rare autosomal recessive disorder characterized by renal abnormalities, obesity, polydactyly, cone-rod dystrophy, and developmental delay. Bifid epiglottis, defined as a cleft in the epiglottis greater than two-thirds its length, is a rare anatomic anomaly that has been associated with BBS.

CASE PRESENTATION: A six year-old female with BBS presented for recurrent pneumonia evaluation. Her past medical history was significant for elevated creatinine, polydactyly, BBS, asthma, and recurrent pneumonia without previous history of stridor. She was diagnosed and treated for a left-sided pneumonia with complete resolution. Twelve days later, she presented with increased work of breathing and home pulse oximetry reading of 87% on room air; thus she was admitted with a diagnosis of right-sided pneumonia. High-Resolution Computed Tomography of the chest indicated no anatomical abnormality. Pulmonology was consulted and performed flexible fiberoptic bronchoscopy, which revealed a bifid epiglottis (Figure 1, 2) and tracheobronchomalacia. Genetic evaluation confirmed a homozygous BBS10 genetic mutation.

DISCUSSION: Typically, bifid epiglottis presents clinically with stridor, recurrent upper respiratory infections, and/or aspiration. Despite known associations of bifid epiglottis and other anatomic malformations, the etiology for the current presentation remains unclear. It has been theorized that simultaneous developmental errors affecting several organ systems, including the epiglottis, occurring between weeks three and ten contribute to characteristic structural anomalies. Despite the rarity of BBS, it is classified as a model ciliopathy, and one should be cognizant of a patient presenting with these syndromic features.

CONCLUSIONS: The combination of bifid epiglottis, homozygous BBS10 genetic mutation, and recurrent pneumonia in this case represents a unique presentation of BBS. This case report highlights the importance of upper airway evaluation in patients with Bardet-Biedl Syndrome.

Reference #1: Gibber, Marc and Abraham, Suzanne. Bassila, Maha K. Int. J. Pediatric Otolaryngology. Extra 6 (2011) 304-305. “Bifid epiglottis with cricopharyngeal dysfunction: A case Report.”

Reference #2: Zaghloul, Norann and Katsanis, Nicholas. "Mechanistic Insights into Bardet-Biedl Syndrome, a Model Ciliopathy." The Journal of Clinical Investigation 119.3 (2009): 428-37.

Reference #3: Ware, Stephanie, Gunay-Aygun, Meral, and Hildebrandt, Friedhelm. Proceedings of the American Thoracic Society, Vol. 8 2011. “Spectrum of Clinical Diseases Caused By Disorders of Primary Cilia.”

DISCLOSURE: The following authors have nothing to disclose: Elizabeth Copenhaver, Nicholas Mulhearn, Safina Kureshi, Kevin Maupin

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Chest. 2013;144(4_MeetingAbstracts):49A. doi:10.1378/chest.1703617

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Postpneumonectomy syndrome (PPS) is a very rare complication of pneumonectomy with incidence of 1 in 640 cases. It results from an excessive mediastinal shift and rotation producing symptomatic airway and esophageal stretching and compression. Because of rarity of condition diagnosis can be missed as in our case.

CASE PRESENTATION: 66 year old male with past medical history of COPD on home oxygen, HTN, CHF and carcinoid tumor s/p right pneumonectomy about 15 years ago, presented to ER with shortness of breath. He had exertional dyspnea for about 2 years and had multiple admissions to different hospitals for same. He complained of orthopnea, leg swelling and dry cough. He was an ex smoker and had a 30 pack year smoking history. On examination patient had crackles at left base and trace leg edema. Labs were unremarkable except for hemoglobin of 10.9 g/dl and BNP of 540 pg/ml. Chest X-ray showed complete opacification of right hemithorax, right mediastinal shift and mild diffuse prominence of pulmonary interstitium on the left. Patient was admitted with working diagnosis of congestive heart failure exacerbation and possible bronchial obstruction. On echocardiogram his EF was 45%. CT scan of the chest showed moderate mediastinal shift to the right; left main stem bronchus stenosis, likely from extrinsic compression. A diagnosis of postpneumonectomy syndrome (PPS) was proposed. PFTs revealed FEV1of 34% predicted and FEV1/FVC ratio was 60. Diagnosis was confirmed with fiberoptic bronchoscopy, which showed that left main stem bronchus was compressed from posterior to anterior; and past this, all segmental orifices were widely patent. CT surgery consult was obtained, but patient declined any surgical intervention and was discharged to home.

DISCUSSION: PPS commonly presents with progressive dyspnea,ocassionally has stridor and heartburn. Onset of symptoms is between 6 months to 29 years after surgery. Female gender, young age at surgery and right sided pneumonectomy are common risk factors. Diagnosis is confirmed with CT chest and fiberoptic bronchoscopy. It is commonly treated with repositioning of mediastinum with saline solution-filled prosthesis with good results.

CONCLUSIONS: Our objective of presenting this case is to enhance awareness of this entity amongst physicians, to enable early recognition of PPS, and to minimize potentially preventable patient morbidity and mortality.

Reference #1: Valji AM, Maziak DE, Shamji FM, Matzinger FR. Postpneumonectomy syndrome: recognition and management. Chest. 1998 Dec; 114(6): 1766-9.

Reference #2: Shen KR, Wain JC, Wright CD, Grillo HC, Mathisen DJ. Postpneumonectomy syndrome: surgical management and long-term results. J Thorac Cardiovasc Surg. 2008 Jun; 135(6): 1210-6; discussion 1216-9. doi:10.1016/j.jtcvs.2007.11.022.

Reference #3: Soll C, Hahnloser D, Frauenfelder T, Russi EW, Weder W, Kestenholz PB. Clinical presentation and treatment. Eur J Cardiothorac Surg. 2009 Feb; 35(2):319-24. doi: 10.1016/j.ejcts.2008.07.070. Epub 2008 Nov 21.

DISCLOSURE: The following authors have nothing to disclose: Muhammad Rizwan, Khawaja Rahman, Zeeshan Ahmad, Zia Rehman, Abid Butt

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Chest. 2013;144(4_MeetingAbstracts):50A. doi:10.1378/chest.1703294

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Localized pulmonary amyloidosis is classified into four types: tracheobronchial amyloidosis (TBA), nodular amyloidosis, infiltrating interstitial amyloidosis, and lymph node amyloidosis (1). We present a case of localized tracheobronchial pulmonary amyloidosis.

CASE PRESENTATION: A 60-year old man was referred for refractory bronchitis associated with abnormal chest imaging. His symptoms included a non-productive cough and shortness of breath that was worse upon awakening. He denied pleurisy, fevers, weight loss, and sick contacts. He also complained of inspiratory wheezing without identifiable triggers. A chest CT scan demonstrated “diffuse wall thickening in the right middle and upper lobe bronchi, with near occlusive narrowing (figure 1).” Further investigation included normal pulmonary function testing with methacholine challenge and a normal echocardiogram. Bronchoscopy with endobronchial biopsy was performed. The bronchoscopy demonstrated diffuse erythema of the mucosa throughout the tracheobronchial tree and prominent submucosal blood vessels (figure 2). Endobronchial biopsies returned congo red stain positive securing the diagnosis.

DISCUSSION: TBA is rare and given the nonspecific symptoms at presentation, diagnosis can be difficult. Coughing, wheezing, hemoptysis, exertional dyspnea, and hoarseness are some of the more common presenting complaints (1,2). In patients with TBA, bronchoscopy may show flat plaques of amyloid material or a nodule that has the appearance of a neoplasm. While these findings may be diffuse, multifocal, or localized, it is key for the diagnosis they not be associated with systemic amyloidosis (3). Given the small database of cases, there are no standardized means to follow progression or large studies on the most effective treatment. An array of therapeutic options exists, ranging from close observation to laser therapies. Currently there are no entirely successful therapies and the efficacy of various drugs is unclear (1). Low-dose radiation takes advantage of the radiosensitive nature of the amyloid protein producing plasma cells. Despite attempts at debulking and repeated laser treatments, the persistent nature and progressive airway narrowing of this disease typically leads to respiratory compromise.

CONCLUSIONS: TBA is a rare disease characterized by the development of amyloid proteins within the bronchial tree. Bronchoscopy is critical to both diagnosis and subsequent therapeutic procedures.

Reference #1: Haiqing Chu, Lan Zhao, et. al: Clinical characteristics of amyloidosis with isolated respiratory system involvement: A review of 13 cases. Annals of Thoracic Medicine. 2013; 7:243-49.

Reference #2: Capizzi S, Betancourt E, Prakash U: Tracheobronchial Amyloidosis. Mayo Clin Proc. 2000; 75:1148-152.

Reference #3: Utz J, Swensen S, Gertz M: Pulmonary Amloidosis The Mayo Clinic Experience from 1980 to 1993. Ann Intern Med. 1996; 124:407-413.

DISCLOSURE: The following authors have nothing to disclose: Erin Crowley, Praveen Mathur, W. Graham Carlos

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Topics: amyloidosis
Chest. 2013;144(4_MeetingAbstracts):51A. doi:10.1378/chest.1693139

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Chronic corticosteroid treatment is known to cause a localized pattern of obesity in the face, supraclavicular, and posterior cervical areas leading to the well-known Cushinoid features. However, abnormal fat distributions, even tumors, have been reported in the episternal area extending to the anterior neck (1).

CASE PRESENTATION: We present the case of a 52 year old Caucasian male who was admitted for a progressive four week history of choking with bilateral arm elevation. He was an active smoker with a 23 pack year smoking history. He was taking oral prednisone which was prescribed six months prior to admission for severe gout. He had both 10 mg and 7.5 mg prednisone tablets at home and was extremely non-compliant with this medication. He would ingest a handful of tablets when the gouty pain occurred, repeating this 2-4 times a week over six months during which he reported a rapid weight gain of 25 lbs. General appearance revealed facial plethora and swelling with Cushinoid features. His neck was also swollen with extensive supraclavicular fat pads. Pemberton's sign was positive causing complete loss of breath and choking with arm elevation. Initial chest X-ray reported widening of the superior mediastinum. A CT angiogram ruled out intrathoracic masses and revealed a normal superior vena cava, however excessive fat in the mediastinum and pericardium were reported. A CT scan of the neck revealed stranding in subcutaneous fat.

DISCUSSION: With the initial constellation of findings, Superior Vena Cava Syndrome (SVCS) was suspected. After negative CT of the chest, the patient’s symptoms were attributed to the excessive fat distribution around his neck and mediastinum from chronic steroid use, which mechanically obstructed the patient's upper airway during arm elevation or neck flexion. As the steroid intake was controlled and dosage tapered down, a complete reversal of symptoms was noted over the course of two weeks.

CONCLUSIONS: Fat distribution in patient's on corticosteroid therapy may vary from the classical Cushinoid description. Previous case reports have described abnormal corticosteroid induced fatty tissue tumors arising from the episternum as "Dewlap" (1). Steroid use and epidural lipomatosis leading to paraparesis has also been documented (2). To the best of our knowledge, there have been no documented cases of anteriolateral fatty neck infiltration due to steroid use that was severe enough to impinge and compress on the airway with arm elevation. The patient’s erratic corticosteroid use over 6 months had led to accelerated Cushinoid features including supraclavicular and mediastinal fat deposition which mimicked SVCS in presentation.

Reference #1: Lucena GE, Bennett WM, Pierre RV. Dewlap A Corticosteroid-Induced Episternal Fatty Tumor. N Engl J Med. 1966;275(15):834-5.

Reference #2: Gupta R, Kumar AN, Gupta V, Madhavan SM, Sharma SK. An Unusual Cause of Paraparesis in a Patient on Chronic Steroid Therapy J Spinal Cord Med. 2007; 30(1):67-69.

DISCLOSURE: The following authors have nothing to disclose: Yenal Harper, Saurabh Aggarwal, Reem Hassan, Paul Morgan, Amin Nadeem, Rohit Arora

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Chest. 2013;144(4_MeetingAbstracts):52A. doi:10.1378/chest.1702457

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Recurrent pneumonia is uncommon in children and typically associated with prematurity, congenital respiratory tract abnormalities, and cardiovascular or neurological diseases. We present the case of a child with recurrent pneumonia and hemoptysis, secondary to a retained airway foreign body, who required a pulmonary resection.

CASE PRESENTATION: EB is a 4-year-old male, with a 2 year history of chronic cough, who presented with a 2-day history of fever, cough, and hemoptysis. He was treated for 6 episodes of right lower lobe (RLL) pneumonia in the previous 2 years. Chest radiograph showed a RLL opacity and intravenous antibiotics were initiated. Chest computed tomography (CT) with contrast showed a nonspecific RLL consolidation with fluid and debris filled airways. Based on history and imaging results, flexible bronchoscopy with bronchoalveolar lavage (BAL) was performed. Flexible bronchoscopy revealed normal bronchial anatomy, but the orifice of the RLL bronchus was edematous, inflamed, and obstructed by granulation tissue. Distal to the obstruction, the visualized RLL airways had minimal secretions, but were dilated and appeared necrotic. BAL culture grew pan-sensitive non-mucoid Pseudomonas aeruginosa and EB was treated with a prolonged course of intravenous antibiotics. Following the antibiotics, repeat chest CT showed persistent RLL consolidation, atelectasis, and bronchiectasis (Figure 1). Repeat flexible bronchoscopy revealed a foreign body embedded in the granulation tissue at the orifice of the RLL. Rigid bronchoscopy could not remove the foreign body. Based on imaging and bronchoscopy findings, the RLL did not appear salvageable; therefore, lung resection was pursued, since surgery offered the opportunity to remove the foreign body and excise the diseased lung. The resected tissue was grossly abnormal with marked airway consolidation, fibrosis, and chronic inflammation (Figure 2). EB tolerated the procedure well with improved aeration of the right lung, and was discharged home on post-operative day five.

DISCUSSION: While most children with FBA fully recover, a retained airway foreign body may lead to serious pulmonary complications, secondary to the resulting inflammation. Recurrent pneumonia, atelectasis, and bronchiectasis are common complications of the prolonged presence of an airway foreign body. Surgery is occasionally required for patients with long-standing pulmonary sequelae.

CONCLUSIONS: Recurrent localized pneumonia in children should raise suspicion for a retained foreign body. Retained airway foreign bodies can lead to long term complications and recurrent pneumonia in children should be investigated with chest CT and flexible bronchoscopy.

Reference #1: Karakoc F, Karadag B, Akbenlioglu C, et al. Foreign body aspiration: what is the outcome?. Pediatr Pulmonol. 2002;34(1):30-6.

DISCLOSURE: The following authors have nothing to disclose: Nicholas Friedman, John Horton, Donald Moffitt, Mark Boseley, Jason Caboot

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Chest. 2013;144(4_MeetingAbstracts):53A. doi:10.1378/chest.1705014

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Hyper Ig-E syndrome (HIES) is a rare multi system disorder characterized by hyperimmunoglobinemia E, eosinophilia, chronic eczema, recurrent skin and pulmonary infections.

CASE PRESENTATION: 52 year old female with long standing history of severe eczema since childhood, asthma, environmental allergies, multiple hospitalizations for MRSA/fungal infections (soft tissue , pneumonia, osteomyelitis), eosinophilia , failure to thrive, who presented to the pulmonologist with complaints of recurrent bronchitis and pneumonia. She was previously seen by an allergist and dermatologist few years ago for the management of severe eczema and allergies. IgE levels were found to be >54000 at that time but she wasn't conclusively diagnosed with HIES and placed on omalizumab trial. Since then, patient clinically deteriorated and began to exhibit the classic manifestation of the disease including the presence of characteristic facies, recurrent MRSA infections/pneumonias, fungal infections, osteoporosis and failure to thrive. Lab work this time revealed IgE levels > 3000 units with normal IgA, G levels. ANA, ANCA, RF, HIV and hepatitis panel were negative. Spiral CT scan of chest revealed new finding of pneumatocele in right upper lobe as compared to prior imaging. PFTs showed restrictive disease pattern with mild decrease in diffusion capacity. At this time, patient was diagnosed with HIES based on elevated Ig E levels, weighted score of > 30 based on NIH scoring system. Prophylactic antibiotic therapy with Bactrim was precluded due to severe sulfa allergy. She is scheduled to receive IVIG therapy as well as Bactrim desensitization.

DISCUSSION: HIES is a rare primary immuno-deficiency disorder inherited in autosomal dominant and recessive patterns. The classic Autosomal Dominant HIES presents with immune abnormalities as mentioned above as well as non immune manifestations which include facial, dental and skeletal abnormalities. Diagnosis is based on NIH scoring and definitive diagnosis requires STAT 3 genetic testing. Management is largely supportive based on prophylactic antibiotic, antifungal therapy and aggressive treatment of infections. Other treatment modalities include IFN gamma, IVIG, cycloscoprine and stem cell transplantation.

CONCLUSIONS: HIES is a diagnostic challenge with broad spectrum of clinical features which can often be attributed to other diagnoses. Although the patient had childhood eczema, hyperimmunoglobunemia and asthma, she presented insidiously with the more classic features of recurrent infections along with presence of pneumatocele at a later age leading to delayed diagnosis. Therefore, it becomes important to have a high index of suspicion along with multidisciplinary team approach to ensure early diagnosis and treatment.

Reference #1: Hyper IgE syndrome: review and future directions. Alexandra F Freeman and Steven M Holland. Expert Review of Clinical Immunology. 1.4 (Nov. 2005) p645.

DISCLOSURE: The following authors have nothing to disclose: Sweta Kakaraparthi, Arwa Mohamed Hosni, Vijay Damarla

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Chest. 2013;144(4_MeetingAbstracts):54A. doi:10.1378/chest.1690510

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheostomy tube provides airway access for mechanical ventilation. The tube can be changed safely at bedside, which simple procedure sometimes results in serious complications unless adequate attention is given.

CASE PRESENTATION: A 55 year old paraplegic man was transferred from a nursing home for possible obstruction of his tracheostomy tube that was placed 5 months ago when he developed acute respiratory failure after motor vehicle accident. Patient had been receiving antibiotics due to fever for unknown duration and the staff at a nursing home failed to introduce suction catheter aimed to clear secretions via tracheostomy tube, which prompted transfer. When seen in our facility, patient was breathing spontaneously and speaking in full sentences without any distress. He reported subjective fever and chill, otherwise the rest of review of system was negative. On physical examinations, vital signs were BP 112/68 Pulse 135 RR 24 Oxygen saturation 100% in ambient air and temperature 101°F. Tracheostomy tube was in place with collar. Suction catheter did not pass through the tracheostomy tube with and without inner cannula in place, suctioning only a small amount of brownish secretions. Inner cannula was inspected to be clean and non-obstructed. Chest exam revealed bilateral mild rhonchi. Laboratory work ups were remarkable for leukocytosis with left shift. Portable X ray of the chest showed tracheostomy tube located outside next to trachea, which finding raised suspicion of tracheostomy malposition. Chest CT scan was performed for further evaluation and demonstrated tracheostomy tube with tip within the superior mediastinal soft tissues, not entering the trachea (Panel A). Extensive pneumomediastinum and high density air fluid level in the superior mediastinum suggestive of a mediastinal hematoma were also noted (Panel B). There was no evidence of tracheal rupture. Tracheostomy tube was removed and 5cc of viscous bloody fluid was obtained with CT guided drainage. Patient maintained oxygen saturation after decannulation and clinically improved with broad spectrum antibiotics for possible mediastinitis.

DISCUSSION: Universally accepted indications for tracheostomy tube change do not exist. It is routinely changed periodically at bedside(1). This case alarms physicians that serious malposition of the tracheostomy tube could happen during the change even when the tracheostomy tract is fully formed and encourages extra attention should be paid.

CONCLUSIONS: Careful management of tracheostomy tube during the change procedure can not be overemphasized.

Reference #1: (1) White AC, Kher S, O’Connor HH. When to change a tracheostomy tube. Respir Care 2010; 55:1069

DISCLOSURE: The following authors have nothing to disclose: Ilhwan Yeo, Ramez Nairooz, Beata Popis-Matejak

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Chest. 2013;144(4_MeetingAbstracts):55A. doi:10.1378/chest.1675147

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Ondine’s curse is a condition which involves autonomic respiratory failure during sleep that is fatal if untreated. This disorder can be inherited and present during infancy as congenital central hypoventilation or it can present during adulthood when it is called primary alveolar hypoventilation. Uncommonly it presents as a brain or high cervical spinal cord injury. Worldwide approximately 200 cases have been reported with very few presenting as adults. We present a case of this rare disease following pontomedullary hemorrhage in an adult woman.

CASE PRESENTATION: A 77 year-old African American woman with history of hypertension and peripheral vascular disease was hospitalized for dizziness secondary to carbon monoxide exposure. On hospital day four she developed new onset slurred speech, right sided facial droop and confusion requiring intubation and mechanical ventilation. Head computer tomography (CT) showed hemorrhage involving the right posterior medulla. She could not be liberated from the ventilator due to frequent, prolonged apneas while asleep consistent with Ondine's curse. These episodes continued despite minimizing sedating medications and trialing various modes of mechanical ventilation. In an effort to increase alveolar ventilation acetazolamide was started. It appeared to be effective as evidenced by decreased apneic spells. Despite less frequent apneas the patient ultimately required a tracheostomy and remains on mechanical ventilation when sleeping.

DISCUSSION: Hypoventilation syndromes are common following cerebrovascular accidents. However, hypoventilation that occurs exclusively during sleep, the dreaded “curse” of Ondine, is quite rare. This case reviews treatment considerations including acetazolamide and early tracheostomy. The tracheostomy simplifies ventilation while asleep whereas the acetazolamide increases ventilatory drive. While our patient remained “cursed” during her inpatient stay, the literature suggests that she may improve over the coming months, regaining her autonomic drive.

CONCLUSIONS: Ondine's Curse is a rare syndrome that affects autonomic ventilatory drive during sleep. This case reviews treatment considerations including acetazolamide and early tracheostomy that may improve overall outcomes.

Reference #1: Panossian L, Daley J. Sleep-disordered breathing. Continuum (Minneap Minn). 2013 Feb;19(1 Sleep Disorders):86-103. doi: 10.1212/01.CON.0000427211.98305.c6. PubMed PMID: 23385696.

Reference #2: Lovell BL, Bullock RE, Anderson KN. An unusual presentation of congenital central hypoventilation syndrome (Ondine's Curse). Emerg Med J. 2010 Mar;27(3):237-8. doi: 10.1136/emj.2009.072215. PubMed PMID: 20304901.

DISCLOSURE: The following authors have nothing to disclose: Hassan Sajjad, Keriann Van Nostrand, W. Graham Carlos

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Chest. 2013;144(4_MeetingAbstracts):56A. doi:10.1378/chest.1703759

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheobronchopathia osteochondroplastica (TPO) is a rare benign disorder of the endobronchial tree. TPO can be associated with various metabolic, inflammatory or neoplastic disorders but its pathogenesis remains unknown[1]. We report a rare case of TPO in a patient with newly-diagnosed mixed connective tissue disease (MCTD).

CASE PRESENTATION: A 54 year old female presented with progressive shortness of breath and non-productive cough. Her past medical history was significant for asthma, gastroesophageal reflux, hypertension and recurrent episodes of bronchitis. Review of systems was positive for atypical chest pain, orthopnea, occasional dizziness and episodes of epistaxis. She was a lifelong non-smoker from Puerto Rico with no occupational exposures. On examination, she had bilateral sclerodactyly, multiple facial telangectasias, bilateral inspiratory crackles on ascultation and swan neck deformity of her right wrist. Her labs showed normal blood count and chemistries. Rheumatologic evaluation revealed positive anti-nuclear antibody, rheumatoid factor, ribonucleoprotein, anti Smith antibody and anti thyroid antibody. A CT scan of her chest showed multiple tracheal excrescences sparing the posterior tracheal wall with calcifications. Her spirometry was normal with moderately reduced DLCO. A subsequent bronchoscopy showed multiple nodular lesions extending throughout the tracheal surface and bilateral bronchi while sparing the posterior membranous wall. Pathological examination of the bronchial biopsy showed bronchial epithelium with squamous metaplasia and underlying ossified connective tissue. The clinical findings, CT scan and biopsy results confirmed the diagnosis of tracheobronchopathia osteochondroplastica. She was also given a diagnosis of MCTD and started on oral steroids. Patient has been followed up on an outpatient basis with progressive decline in her diffusion capacity.

DISCUSSION: Cartilaginous airway thickening has been described as a known clinical entity for many years. The differential diagnosis usually include TPO, atrophic polychondritis, transbronchial amyloidosis or a granulomatous pathology such as Wegener’s[1]. TPO is a benign process that involves the formation of multiple cartilaginous or bony sub mucosal nodules that project into the transbronchial lumen. There appears to be an association between chronic inflammatory states and TPO. Although some case reports of relapsing polycondritis and TPO exist there are very few cases of association with autoimmmune rheumatologic processes specifically MCTD.

CONCLUSIONS: TPO is a rare clinical entity that should be considered in patients with abnormal CT findings characteristic of cartilaginous tracheal involvement particularly in chronic inflammatory states like MCTD.

Reference #1: 1. Prince JS, Duhamel DR, Levin DL, et al. Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation. Radiographics 2002; S215-230

DISCLOSURE: The following authors have nothing to disclose: Padmanabhan Premkumar, Mohsin Ehsan, Bimalin Lahiri

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Chest. 2013;144(4_MeetingAbstracts):57A. doi:10.1378/chest.1703257

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a viral disease that typically affects the larynx, however in rare cases can involve pulmonary parenchyma. We report a case of RRP with pulmonary metastasis.

CASE PRESENTATION: A 33-year-old man, with past medical history of RRP diagnosed at age 28, requiring serial debridement of papillomas, presented with fever, night sweats and productive cough. Two days prior he underwent bronchoscopy with laser destruction of recurrent papillomas of the nasopharynx, larynx, and trachea. It was complicated by post-procedure nausea and emesis. On admission, he was febrile (104.3F) and tachycardic (130 bpm). SpO2 was 94% on room air. CXR and chest CT revealed multiple solid and cavitary nodules with air-fluid levels. AFB, fungal and auto-immune assays were unrevealing. He was initially treated with vancomycin and piperacillin/tazobactam, but converted to ciprofloxacin based on a sputum culture that grew Serratia. Symptomatically he improved; he will be followed closely in pulmonary clinic with repeat CT scan.

DISCUSSION: RRP is the result of proliferation of squamous papillomas in the aerodigestive tract. It is associated with HPV-6 and HPV-11. Two forms of disease are recognized: an aggressive form arising early in life, likely secondary to vertical transmission through an infected birth canal, and a less aggressive form typically arising in adulthood. Of interest, this patient’s mother died of cervical cancer at age 48. Pulmonary papillomatosis has mainly been reported in children with aggressive disease or after multiple laryngeo-tracheal interventions. It predisposes to recurrent lower respiratory tract infections (LRTI), nodulo-cystic and cavitary lung lesions and respiratory failure due to parenchymal damage. Transformation to squamous cell carcinoma has been reported in 1-2% of patients treated over 10 years. Surgery is the mainstay of treatment for laryngeal involvement, however adjuvant medical treatment is indicated for rapid regrowth of lesions, airway compromise, or distal involvement. Trial data is limited but various therapies have been studied including interferon alpha, anti-virals, photodynamic therapy, retinoids, COX-2 inhibitors, and tyrosine kinase inhibitors.

CONCLUSIONS: LRTI in a patient with RRP should prompt evaluation for broncho-pulmonary progression. Pulmonary papillomatosis is a severe complication of RRP and can be associated with malignant transformation.

Reference #1: Blackledge FA and Anand VK, Tracheobronchial extension of recurrent respiratory papillomatosis, Ann Otol Rhinol Laryngol 2000.

Reference #2: Derkay CS and Wiatrak BM, Recurrent respiratory papillomatosis: a review, The Laryngoscope 2008

Reference #3: Limsukon A, et.al., Regression of recurrent respiratory papillomatosis with Celexocib and Erlotinib combination therapy, Chest 2009

DISCLOSURE: The following authors have nothing to disclose: Nicholas Braus, Haamid Siddique, Trina Hollatz

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Chest. 2013;144(4_MeetingAbstracts):58A. doi:10.1378/chest.1701075

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Among the myriad clinical presentations of lung cancer, life threatening hemoptysis may be the most difficult to treat. Identification of the site of bleeding within the airways plays a key role in the approach to management, as the location dictates the most efficacious treatment option. The most common treatments include pharmacological, bronchoscopic intervention, vascular embolization and surgical resection. We herein report a novel approach to massive hemoptysis in a patient found to have an actively bleeding carinal mass invading and obstructing the right main bronchus.

CASE PRESENTATION: 66-year-old Caucasian female with past medical history of hypertension and smoking presented with massive hemoptysis which was immediately and successfully controlled and airway patency reestablished with the insertion of an endobronchial-covered stent. The mass was identified at bronchoscopy as squamous cell carcinoma and the patient was later referred for radiation therapy. Four weeks later, after receiving a total of 5 sessions of radiotherapy, the patient presented with throat discomfort and odynophagia. Computed tomography scan showed tumor reduction with increased lumen size of the right main bronchus and migration of the stent into the hypopharynx. The stent was successfully removed without incident. No episodes of additional hemoptysis occurred.

DISCUSSION: When alternative treatment modalities fail or are precluded by the central location of the bleeding site, covered endobronchial stent placement should be considered an indispensible option in this select group of patients, as it can achieve immediate airway patency as well as tamponade of the bleeding focus.

CONCLUSIONS: Complications of endobronchial stent placement including migration and perforation should be identified and treated early.

Reference #1: Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis. Chest. 2003; 124:1993-9.

Reference #2: Brandes JC, Schmidt E, Yung R. Occlusive endobronchial stent placement as a novel management approach to massive hemoptysis from lung cancer. J Thorac Oncol. 2008; 3:1071-2

Reference #3: Lee SA, Kim do H, Jeon GS. Covered bronchial stent insertion to manage airway obstruction with hemoptysis caused by lung cancer. Korean J Radiol. 2012; 13: 515-20.

DISCLOSURE: The following authors have nothing to disclose: Fernando Gonzalez-Ibarra, Jyoti Matta, Basheer Tashtoush, Sahar Eivaz-Mohammadi, Hazem Alsaadi, Andrew Novick

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Chest. 2013;144(4_MeetingAbstracts):59A. doi:10.1378/chest.1704827

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Aerodigestive fungal infections are commonly overlooked as they are often ascribed as colonization. In our review of the literature, active fungal infections with Candida, specifically Candida glabrata, were linked to immunocompromised patients with chronic mediastinal infection with Candida glabrata being rare (1,2). We report a unique case of chronic aerodigestive infection with subsequent mass formation and esophageal constriction secondary to Candida glabrata in an immunocompetent patient.

CASE PRESENTATION: The patient is a 47-year-old male, who presented with nausea and vomiting for 3 months. Upon further workup with imaging studies (computed tomography (CT) abdomen/pelvis) to rule out anatomical obstruction, the patient was found to have a mediastinal mass, involving the esophagus; an EGD showed anatomical obstruction of the distal part of the esophagus (Image 2). Esophageal biopsies were performed, and an esophageal stent was placed. The patient initially underwent an autofluorescence bronchoscopy and bronchoalveolar lavage to assess for airway invasion. There was no direct invasion seen, but there was extrinsic compression of the trachea (Image 1). The respiratory culture from the bronchoalveolar lavage was positive for Candida species, not albicans. The esophageal biopsy was non-diagnostic, so the primary team consulted interventional pulmonology for an endobronchial ultrasound guided transbronchial needle aspiration and biopsy. The pathology from the biopsies was positive for Candida glabrata, sensitive to fluconazole. The patient was started on the appropriate treatment.

DISCUSSION: Per our literature review this case is the first report of chronic mediastinal infection, causing mass effect secondary to Candida glabrata in an immunocompetent patient. The presenter will discuss salient features and management related to this rare presentation.

CONCLUSIONS: The general workup of a mediastinal mass should include fungal organisms, including Candida glabrata.

Reference #1: Speletas M, Vyzantiadis TA, Kalala F, Plastiras D, Kokoviadou K, Antoniadis A, Korantzis I. Pneumonia caused by Candida krusei and Candida glabrata in a patient with chronic myeloid leukemia receiving imatinib mesylate treatment. Med Mycol. 2008 May;46(3):259-63

Reference #2: Johnson DC. Chronic candidal bronchitis: a consecutive series. Open Respir Med J. 2012;6:145-9

DISCLOSURE: The following authors have nothing to disclose: Christine Charaf, Rohan Mankikar, Eric Flenaugh, Kenneth Franco

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Chest. 2013;144(4_MeetingAbstracts):60A. doi:10.1378/chest.1704930

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Amyloidosis isolated to the respiratory tract is an uncommon presentation1.

CASE PRESENTATION: A 69 year old Caucasian male initially presented to ENT with hoarseness. Thickening of nasal turbinates was biopsied revealing amyloid derived from kappa light chain, AL-kappa. He reported no other symptoms. He began treatment with steroids and initially with lenalinomide, which after adverse reaction was switched to bortezomib. One year diagnosis he developed dyspnea on exertion. After a syncopal event he was referred for pulmonary evaluation. On the day of his pulmonary appointment his vital signs were: 98 degrees F , BP 123/70, pulse 64, SpO2 98%. Pulmonary function tests showed normal spirometry, normal lung volumes, and near normal diffusion capacity. The echocardiogram showed an ejection fraction 40%. BNP was within normal limits at 43; EKG with normal sinus rhythm; no signs of conduction disease. However, chest CT demonstrated ground glass opacities in bilateral apices and diffuse thickening of the wall of trachea and major bronchi. Bronchoscopy revealed edematous, erythematous and friable airways which bled easily. Biopsy demonstrated amyloid in bronchiolar stroma. Given the progression of disease, the decision was made to continue steroids but add melphalan, an alkylating agent, combined with a newly approved proteosome inhibitor carfilzomib. His dyspnea almost completely resolved with 2 months of therapy. A follow up chest CT is pending. The abdominal fat pat biopsy by fine needle aspiration is negative for amyloid deposition, however a surgical fat biopsy, which would provide higher sensitivity, is pending.

DISCUSSION: According to a case series of 55 patients with pulmonary amyloidosis, published in the Annals of Internal Medicine2, only 17 patients had localized amyloidosis. Of the latter group, 4 cases had tracheobronchial amyloidosis. Usual presentation is with dyspnea and cough with possible hemoptysis in the 5th and 6th decades of life. Radiologic findings generally demonstrate thickened airways3. The mean survival of patients localized pulmonary amyloid has been reported to be less than 4 years1.

CONCLUSIONS: Unless a surgical fat pad biopsy shows evidence of systemic amyloidosis, this patient has amyloidosis limited to the respiratory tract.

Reference #1: Chu H, Zhao L, Zhang Z, Gui T, Yi X, Sun X. Clinical characteristics of amyloidosis with isolated respiratory system involvement: A review of 13 cases. Ann Thorac Med. 2012 Oct;7(4):243-9.

Reference #2: Utz JP, Swensen SJ, Gertz MA. Pulmonary amyloidosis. The Mayo Clinic experience from 1980 to 1993. Ann Intern Med. 1996;124:407-413.

Reference #3: Lachmann HJ, Hawkins PN. Amyloidosis and the lung. Chron Respir Dis. 2006;3:203-14.

DISCLOSURE: The following authors have nothing to disclose: Ryan Bohle, Maria Picken, Sunita Kumar

No Product/Research Disclosure Information

Topics: amyloidosis
Chest. 2013;144(4_MeetingAbstracts):61A. doi:10.1378/chest.1704798

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Wheezing is a nonspecific symptom that usually heralds obstructive airway disease. We present a case of airway obstruction due to broncholithiasis mimicking asthma.

CASE PRESENTATION: A 58-year-old woman was seen due to asthma exacerbations and recurrent left lower lobe pneumonia. She complained of wheezing and dry cough, without triggers. Her asthma was treated with inhaled corticosteroids and albuterol without control. History of hypertension, hyperlipidemia and seasonal allergies and she was nonsmoker. Exam: BP 118/65, HR 64, RR 17, Temp 97°F, Sat 97% on room air. Pulmonary auscultation with central wheezing. Spirometry FVC: 2.43(79%), FEV1: 1.52 (62%) and FEV1/FVC: 63%. Diagnosed with chronic persistant asthma and salmeterol/fluticasone was initiated without symptom control. The patient then was admitted to the hospital with left lower lobe pneumonia, the chest radiograph revealed a left lower lobe consolidation, multiple calcified granulomata and calcified mediastial and hilar adenopathy. CT scan of the chest revealed a calcified mass within the left main bronchus, a left lower lobe infiltrate, and multiple bilateral calcified granulomas. Flexible bronchoscopy confirmed a broncholith in the distal left mainstem bronchus obstructing the left lower lobe. A rigid bronchoscopy and broncholithectomy was performed without complications. Evaluation for granulomatous disease was unrevealing. Gross pathology showed a 2x1.2x1cm broncholith. The patient’s symptoms completely resolved 3 months after endoscopic broncholithectomy and bronchodilators were discontinued due to complete symptom resolution.

DISCUSSION: Broncholithiasis in the US is most commonly due to Histoplasmosis. The patient presented with symptoms of recurrent pneumonia in the left lower lobe and wheezing. CT scan of the chest revealed pulmonary parenchymal and lymph node calcifications. Broncholiths are best removed surgically especially if causing hemoptysis or fistula with adjacent structures. Endoscopic removal is reserved for lose endobronchial lesions that can be easlily retrieved by flexible or rigid bronchoscopy.

CONCLUSIONS: Broncholithiasis is an uncommon condition mostly caused by granulomatous infection but can be due to other conditions previously described in the literature. In our case, the patient had been treated for asthma for several years without paying much attention to her chest imaging studies. Imaging studies can provide with clues regarding possible causes of airway obstruction.

Reference #1: Anwer M, Venkatram S. J Bronchology Interv Pulmonol. 2011 Apr;18(2):181-3.

Reference #2: Menivale F, Deslee GF, Vallerand H, Toubas O, Delepine G, Guillou PJ, Lebargy F. Ann Thorac Surg 2005;79:1774-6.

Reference #3: Cerfolio RJ, Bryant AS, Maniscalco L. J Thorac Cardiovasc Surg. 2008 Jul;136(1):186-90.

DISCLOSURE: The following authors have nothing to disclose: Paula Duran, Juan Sanchez

No Product/Research Disclosure Information

Topics: asthma , wheezing
Chest. 2013;144(4_MeetingAbstracts):62A. doi:10.1378/chest.1704835

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: A case of diffuse alveolar hemorrhage (DAH) in a patient with Systemic Lupus Erythematosus (SLE) and Cryptococcus Pneumonia.

CASE PRESENTATION: An 18 year old female from Burma with a history of SLE diagnosed 2 years ago, on prednisone, presented with fever and confusion. Lab work revealed methicillin sensitive staphylococcus aureus (MSSA) bacteremia as well as hypocomplementemia [C3- 40 mg/dL (normal 90-180), C4- 8 mg/dL (normal: 8- 36)]. MRI of brain was obtained that showed basal ganglia and periventricular white matter intensities suggestive of lupus vasculitis. Cerebro Spinal Fluid (CSF) analysis was normal. Patient was treated with cefazolin and started on methylprednisolone 1 gm/day for 3 days followed by prednisone taper, on which she showed neurological improvement. However, on 6th hospital day, she developed rapidly progressive respiratory distress with dry cough (no hemoptysis) and hypoxemic respiratory failure requiring 10 L Oxygen via Oxymizer. Chest X-ray & CT-scan chest showed bilateral alveolar infiltrates. Bronchoscopy with Broncho Alveolar Lavage (BAL) revealed hemorrhagic fluid which progressively increased in subsequent aliquots. Culture of the BAL revealed Cryptococcus neoformans which was subsequently also found in blood culture. Patient was also treated with Amphotericin B (0.7 mg/kg per day) plus flucytosine (100 mg/kg per day) for 2 weeks followed by fluconazole for 1 year.

DISCUSSION: A large spectrum of pulmonary manifestations can occur in SLE. DAH is an infrequent but potentially serious complication of SLE. Up to a third of patients with diffuse alveolar hemorrhage may not have hemoptysis. We present a rare case of alveolar hemorrhage in a lupus patient who was also found to have systemic cryptococossis. Cryptoccal infections can infect immunocompromised hosts but has not been reported to cause DAH. Patients with severe pulmonary or disseminated cryptococcal disease should be managed as for central nervous system disease, even in the setting of normal findings on spinal fluid examination.

CONCLUSIONS: Early BAL is necessary in DAH to rule out infections in addition to establishing the diagnoses.

Reference #1: Lara, Abigail R., and Marvin I. Schwarz. "Diffuse alveolar hemorrhage." CHEST Journal 137.5 (2010): 1164-1171.

Reference #2: Carmier, D., et al. "Respiratory involvement in systemic lupus erythematosus." Revue des Maladies Respiratoires 27.8 (2010): e66-e78.

Reference #3: Kamen, Diane L., and Charlie Strange. "Pulmonary manifestations of systemic lupus erythematosus." Clinics in chest medicine 31.3 (2010): 479.

DISCLOSURE: The following authors have nothing to disclose: Abhishek Singla, Pranjal Sharma, Jayanth Adusumalli, Tammy Wichman

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Chest. 2013;144(4_MeetingAbstracts):63A. doi:10.1378/chest.1704973

SESSION TITLE: Bronchology Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Patients that present with recurrent hemoptysis after thoracic aneurismal repair should be highly suspected for collateral bronchial artery circulation as a potential cause of persistent pulmonary hemorrhage.

CASE PRESENTATION: Seventy-five year old female presents with a 6 month history of recurrent hemoptysis. Her past medical history is significant for descending thoracic aneurysm repaired with stent, non small cell lung CA s/p left lower lobe (LLL) resection, and aspergillosis infection diagnosed by bronchoscopic biopsy. Hemoptysis continued throughout the admission despite treatment for aspergillosis, and multiple bronchoscopies performed. On day 5 of admission patient developed massive hemoptysis, requiring intubation for airway protection and was transferred to the intensive care unit. Follow up bronchoscopy showed diffuse right lower lobe hemorrhage and oozing from the LLL stump, with no clear source of bleeding. The following day a pulmonary angiogram also failed to show areas of active bleeding. Throughout this time the patient continued to have mild hemoptysis but remained afebrile. On day 10 the patient underwent a bronchial artery angiography, which discovered collateral circulation from the thyrocervical trunk to the right bronchial artery. This was thought to be the source of pulmonary hemorrhage and embolization was performed. Repeat bronchoscopy the following day showed scattered blood clots bilaterally but no active bleeding. Patient was transferred to a regional floor one day later, and discharged to home three days after, with no recurrent episodes of hemoptysis.

DISCUSSION: This case represents the importance of understanding the anatomical variation of the bronchial arteries in the setting of patients with previous endovascular repair and persistent hemoptysis

CONCLUSIONS: Patients that fail to show a clear source of bleeding with routine thoracic angiography and bronchoscopy should have angiographic evaluation of all possible collaterals.

Reference #1: Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive revie. Radiographics. 2002 Nov-Dec;22(6):1395-409. PMID:12432111

DISCLOSURE: The following authors have nothing to disclose: Peter Abdelmessieh

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Chest. 2013;144(4_MeetingAbstracts):64A. doi:10.1378/chest.1701673

SESSION TITLE: Airway Management Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Routine endotracheal suctioning techniques are unable to remove adherent secretions and biofilm on the endotracheal (ET) tube, resulting in a narrowed airway, increased work of breathing, and colonization by ventilator associated pneumonia (VAP) organisms. The purpose of this study is to compare the effectiveness of removing adherent endotracheal tube secretions with the use of the EndOclear catheter prior to weaning trials compared to the effects of routine suctioning prior to weaning trials.

METHODS: This is a two year retrospective study of all adult patients, age 18 or older, admitted the Intensive Care Unit who were on the ventilator greater than 24 hours, and who meet the general criteria for the sedation awakening and weaning trials. 2011 ventilator days, ICU length of stay (LOS), hospital LOS, and VAP was compared with 2012 patients who had their endotracheal tubes cleared with the EndoClear catheter prior to the weaning trial.

RESULTS: 550 cases were reviewed during 2011 and 562 cases in 2012. Previous to the initiation of endotracheal tube being cleared with the EndoClear catheter ventilator days were 4.3, ICU LOS was 5.2, and hospital LOS was 9.3. After the initiation of the EndOclear tube there was a decrease in ventilator days by 1 day. ICU LOS decreased from 9.3 by 0.9 days and the hospital LOS decreased from 5.2 by 1 day. Our VAP rate went from 1.2 in 2011 to 0 in 2012 and continues to remain at 0. There was an estimates savings of $536,710 in 2012 with the use of the EndOclear catheter prior to weaning trials.

CONCLUSIONS: The removal of adherent endotracheal tube secretions with the use of the EndOclear catheter prior to weaning trials provides better patient care outcomes and provides a costs savings to the hospital.

CLINICAL IMPLICATIONS: Utilizing the EndOclear catheter is a safer, more effective way to remove adherent secretions and biofilm on the endotracheal tube then routine suctioning technique resulting in decreased time on the ventilator.

DISCLOSURE: The following authors have nothing to disclose: Linda Schofield, Gary Saurs

No Product/Research Disclosure Information

Chest. 2013;144(4_MeetingAbstracts):65A. doi:10.1378/chest.1703669

SESSION TITLE: Airway Management Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Heliox - Helium-oxygen mixture, has been used since the 1930s, to alleviate symptoms of upper airway obstruction. Therapeutic efficacy data mainly stems from pediatric literature. There is relative paucity of data pertaining to its efficacy in Adults. We report our experience with Heliox used for the management of upper airway obstruction and post-extubation stridor in adults at our institution.

METHODS: A retrospective analysis of adult cases of post-extubation stridor (PES) and stridor attributed to primary upper airway obstruction (UAO) managed with Heliox in our institution from January 2011 through December 2012.

RESULTS: 28 patients were identified from medical records who received Heliox. Upper airway obstruction was the main indication in all of these patients. 15 had primary UAO and 13 had PES. In the UAO subgroup, 6 patients (40%) were eventually intubated. Of those 6, 5 (83%) had a tumor mass causing upper airway obstruction, 2 underwent tracheostomy, and 4 were eventually extubated. The mean duration of treatment with Heliox was 20.2 hours. Nine of the 15 (60%) did not require intubation. Their mean duration of Heliox was 16.7 hours. In the PES subgroup, 4 (31%) required re-intubation and 9 (69%) stayed extubated. The mean time from extubation to initiation of Heliox was 247 minutes for patients who did not require re-intubation versus 500 minutes for patients who did require re-intubation (statistically insignificant difference with a p-value of 0.28). The mean duration of Heliox therapy for patients who required re-intubation was 23.25 hours compared to 21.3 hours for patients who did not.

CONCLUSIONS: 1. Heliox administration may be a simple and efficacious adjunctive therapy in management of acute respiratory failure secondary to upper airway obstruction in adults. 2. A prospective study is needed to further validate the therapeutic efficacy of Heliox in Adults.

CLINICAL IMPLICATIONS: 1. Earlier initiation of Heliox may predispose to improved outcomes. 2. Heliox may be considered in patients with UAO due to non-neoplastic etiology

DISCLOSURE: The following authors have nothing to disclose: G Zacharia Reagle, Reza Ronaghi, Christopher Russo, Wade Veneman, Vijay Balasubramanian

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Chest. 2013;144(4_MeetingAbstracts):66A. doi:10.1378/chest.1703680

SESSION TITLE: Airway Management Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Bedside percutaneous tracheostomy (PT) is now commonly performed in intensive care units. Obesity has traditionally been considered a relative contraindication to PT with surgical tracheostomy being preferred. While previous studies have suggested the safety of PT in obese patients, they have been limited by low prevalence of obesity. The purpose of this study was to evaluate the safety of PT in obese patients.

METHODS: Retrospective chart review was performed on patients who underwent PT between January 2010 and December 2012. Information on demographics, height, weight, neck or tracheal anatomy, and procedural data were collected and compared with non-obese (NO) patients. Bleeding more than 10 mL was considered significant. Short neck was defined as cricoid-sternal notch distance less than 1.5 cm. Hypoxia was defined as SpO2 less than 90%. Other complications were identified as hypoxia, balloon rupture, or pneumothorax.

RESULTS: 101 records were available for review; 39 (39%) were severely obese. There was no statistically significant difference in demographics and duration of intubation. Obese patients were significantly more likely to have a deep trachea (23.7% versus 3.4%, p=0.002) and short neck (18.4% versus 5.1%, p = 0.035). There was a significantly increased risk of other complications in obese patients (17.9% versus 5%, p=0.037), the most common complication being hypoxia. There was a trend towards increased pressor requirement in non-obese patients (20.3% versus 7.9%, p = 0.098). There was no significant difference in bleeding, loss of airway, incision extension, or need for tracheostomy change.

CONCLUSIONS: PT can be safely performed in severely obese patients.

CLINICAL IMPLICATIONS: Although limited by retrospective nature, this study reports the safety of PT in a patient population with a high obesity prevalence.

DISCLOSURE: The following authors have nothing to disclose: David Chambers, Rebecca Cloyes, Abdulgadir Adam, Shaheen Islam

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Chest. 2013;144(4_MeetingAbstracts):67A. doi:10.1378/chest.1702284

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: The FEV1/FVC ratio can be reduced in asthma, but the degree of reduction from predicted values to diagnose asthma has not been well established. The FEV1/FVC ratio Z-score is the difference between actual and predicted FEV1/FVC ratio, normalized to the standard deviation of predicted ratio from a healthy population. The optimum Z-score depends upon the prevalence of asthma in the population (i.e. pre-test probability). Accordingly, we wanted to estimate the FEV1/FVC ratio Z-score threshold with the highest accuracy for the diagnosis of airflow limitation in a population of asthmatics for different pre-test probabilities.

METHODS: Data for this analysis came from four trials of asthmatics enrolled in trials from the Asthma Clinical Research Centers. Measured and predicted FEV1/FVC ratios were obtained with calculation of the Z-score for each participant. Across a range of hypothetical asthma prevalence and Z-score thresholds, overall diagnostic accuracy was calculated.

RESULTS: 1608 participants were included (median age 39 years, 71% female and 61% Caucasian). The median age of asthma onset was 13 years, with median ACQ and ASUI scores of 1.71 and 0.80, respectively. The median FEV1% predicted was 84%. In a population with 50% prevalence of asthma, the highest accuracy (68%) is achieved with a Z-score threshold of -1.0 (16th percentile), corresponding to a 6% reduction from predicted ratio. If the prevalence of asthma is 5%, then the optimum Z-score is -2.0 (2nd percentile), corresponding to a 12% reduction from predicted ratio.

CONCLUSIONS: Use of a 6% reduction in FEV1/FVC ratio from predicted ratio yields the best accuracy for diagnosing asthma in a symptomatic population with possible asthma (prevalence of 50%). In contrast, when screening at the population level, a 12% reduction in FEV1/FVC ratio would afford the highest accuracy.

CLINICAL IMPLICATIONS: When interpreting spirometry, consideration of the pre-test probability is an important consideration in diagnosis of asthma based on airflow limitation.

DISCLOSURE: The following authors have nothing to disclose: Allison Lambert, M. Bradley Drummond, Christine Wei, Meredith McCormack, Robert Wise

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Chest. 2013;144(4_MeetingAbstracts):68A. doi:10.1378/chest.1703596

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: As a component of a larger collaborative project being conducted by the Comparative Effectiveness Research Hub (CER-HUB), we evaluated impacts of an asthma specific documentation template embedded into the electronic medical record (EMR) at one study site on measures of asthma control and medication therapy adjustment compared to other study sites without this decision support.

METHODS: The population included patients at each of six CER-HUB sites age 14 years or older who met modified HEDIS criteria for persistent asthma between 2006-2010. We developed data extraction algorithms for determining asthma control in the study site EMRs based on elements in the NHLBI Expert Panel Report-3. 240 patients at each site (sampled randomly) were assessed for asthma control and changes in medications. One site had an asthma EMR documentation template with queries relating to rescue inhaler use and symptom frequency.

RESULTS: 1440 unique asthma patients underwent medical record abstraction (240 patients at the site with the documentation template). The percentage of patients classified as having an “out-of-control” asthma event was significantly higher at the site with structured note (91.3% vs. overall site average of 68.8%, p<0.001). For patients identified as having an out-of-control event, capture of specific symptoms (e.g., nocturnal awakening > 2 times weekly, 43.8 % vs. 25.3%, p<0.01) and frequency of medication change (68.5% vs. 41.4%, p<0.001) were also significantly higher at the site using a documentation template compared to the overall average.

CONCLUSIONS: We observed that a site with a structured EMR template focused on asthma control reported a higher percentage of patients with out-of-control events, and in the out-of-control subset, better characterization of asthma symptoms and increased medication changes compared to sites without the structured note. It is unlikely that these substantial differences are attributable solely to population characteristics or variability in asthma epidemiology between the sites.

CLINICAL IMPLICATIONS: EMR documentation templates appear to be useful clinical decision support in asthma, particularly in identifying uncontrolled disease and prompting providers to modify therapy.

DISCLOSURE: The following authors have nothing to disclose: Mark Millard, Elisa Priest, Louann Cole, Rich Mularski, Brian Hazlehurst, Andrew Masica

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Chest. 2013;144(4_MeetingAbstracts):69A. doi:10.1378/chest.1700037

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: To study the values of FENO in some of respiratory diseases and the relationship of the value of FENO with desease stage and pulmonary function tests

METHODS: This was a prospective study. FeNO has been measured in 111 patients : 41 patients with a diagnosis of asthma , 3 with GERD, 19 with bronchectasia, 11 with sarcoidosis, 23 with COPD , 14 with secondary Pulmonary Hipertension. FeNO was measured by chemoluminescence using an online nitric oxide monitor (NIOX MINO; Aerocrine AB, Solna, Sweden), according to the 1999 American Thoracic Society (ATS) guidelines and consistent with the ATS guidelines published in 2005. We used for independent samples t test and ANOVA for comparison of average values FENO according to diagnosis and respiratory tests. Significance was defined as a p value of < 0.05. Statistical tests are two-sided.

RESULTS: The mean FENO for patients with asthma was 30.5pp ±30.7SD with range 5 - 124. p=0.003. The mean FENO is higher in moderate stage 91ppb, intermittente stage 80.5ppb, severe 63ppb and mild stage 60ppb.The mean of FENO in the patients with asthma with normal value of IgE and high value of IgE were 15.8 ±13.4SD and 64.9 ±28.1SD respectively. p<0.01.The mean of FENO in the diseases with obstruction of the small airway was 18.2±20.4SD with range 5 - 63.The mean of FENO in GERD with obstruction of the small airway was 6.7 ±2.1SD , the mean of FENO in patients with asthma with obstruction of the small airway was 27.0 ±25.0SD.p=0.2. (the difference is very high but it has not brought significant change due to the small size of the sample) ., The mean of FENO in COPD was higher in the second stage (41) than the third stage (13.5) and the fourth stage ( 7.7) The mean FENO in patients with secondary pulmonary hypertension was 12.2 ±5.6D with range 5 - 20.

CONCLUSIONS: The value of FeNO in astma is not correlated with the values of FEV1 but with the activity of eosinophilc inflammation and atopy. There was significant change between the mean of FENO to the stages of COPD. There was negative moderate correlation between the value of FENO and PSAP.

CLINICAL IMPLICATIONS: The use of FeNO in daily practice is very useful in differential diagnosis of obstructive bronchial diseases,in determing of the severety of inflammation and pulmonary hypertention.

DISCLOSURE: The following authors have nothing to disclose: Eugerta Dilka, Eritian Tashi, Armela Cuko, Jeta Beli, Elenka Shehu, Roland Kore, Dhimitraq Argjiri, Arben Tanka, Edlira Ndreu, Esmeralda Nushi, Perlat Kapisyzi

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Chest. 2013;144(4_MeetingAbstracts):70A. doi:10.1378/chest.1698588

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: A comparative assessment of peripheral motor nerves functions in asthma patients organized to two groups according to spirometric severity; and to evaluate for correlation(s) of patients' characteristics and spirometric indices with peripheral motor nerves functions in these patients.

METHODS: We included 60 chronic persistent stable asthma patients (40 females and 20 males) diagnosed as per GINA guidelines. They were organized to two groups: 30 patients with FEV1/FVC ratio > 70% (Group 1) and 30 patients with FEV1/FVC ratio ≤70% (Group 2). Electrophysiological study was carried out to assess amplitude, latency and conduction velocity of four motor nerves - median nerve, ulnar nerve, common peroneal nerve and tibial nerve. Significance of difference between identical parameters of two groups was analyzed. Correlations of patients` characteristics and spirometric indices with the nerve function parameters were also analyzed.

RESULTS: There was no difference between groups regarding age (28.47±9.24 year vs. 29.67±4.66 year; p value=0.528) and height (p value= 0.738). Group 2 patients had significantly more duration of illness (11.23 ± 3.32 year vs. 5.57 ± 3.18 year) and lower FEV1 (2.130 ± 0.381 L vs. 2.856 ± 0.427 L), lower PEFR (4.879 ± 0.576 L/s vs. 5.988 ± 0.820 L/s). In Group 2, conduction velocities of all nerves were significantly decreased, but the latency of median motor nerve only was prolonged significantly. The decreased in amplitudes of motor nerves in Group 2 were not statistically significant. Duration of illness, FEV1 and PEFR were significantly correlated with nerves functions parameters.

CONCLUSIONS: We found that asthma patients with more disease severity had decreased conduction velocities of all studied motor nerves and increased latency of median motor nerve. Duration of illness, FEV1 and FVC were correlated with peripheral motor nerves functions.

CLINICAL IMPLICATIONS: As peripheral motor nerves are often not suspected to be involved in asthma patients, the peripheral motor nerve dysfunctions in many of them remain under diagnosed and may affect the quality of life in many of these patients.

DISCLOSURE: The following authors have nothing to disclose: Dipti Agarwal, Sushma Sood, Prem Parkash Gupta

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Topics: asthma , motor nerve
Chest. 2013;144(4_MeetingAbstracts):71A. doi:10.1378/chest.1703281

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: While treatments and interventions for effective asthma management are well understood, asthma control continues to be suboptimal, resulting in frequent exacerbations, high healthcare utilization and costs, and decreased quality of life. Ambulatory monitoring of inhaled bronchodilators use through sensors and smartphone apps has the potential to improve self-management and provide physicians with a new perspective on disease control. This report summarizes interim results, as measured by frequency of rescue inhaler use, from an ongoing clinical trial.

METHODS: Patients at a hospital system in California are enrolled in a randomized, controlled trial, with allocation stratified by insurance type, language (Spanish or English) and level of control. Intervention group participants receive inhaler sensors and feedback through smartphone apps and online interfaces. Intervention patients’ physicians receive access to this data, and alerts if a patient falls below control thresholds. Control group patients are outfitted with sensors but do not receive feedback.

RESULTS: At 16 weeks, 216 patients (107 intervention, 99 control) had been enrolled (49% of 440 person target). At enrollment, the mean number of events per week did not differ (p=0.70) between control (3.55 ±5.74) and intervention groups (3.23 ±6.58). In a linear mixed model, over the first 60 days of participation the intervention group used their inhaler 0.14 times fewer per day or 1 event per week (p = 0.046) fewer when compared to the control group.

CONCLUSIONS: Remote monitoring of rescue inhaler use provides information valuable to guide and improve self-management and may help physicians identify patients who need more attention. Subsequent analyses will investigate any effects on healthcare utilization.

CLINICAL IMPLICATIONS: In standard practice, providers spend half of an appointment interviewing the patient about medication adherence, use of rescue inhalers and symptoms. Patient information recalled from the past 3-6 months is often unreliable and biased. Early results from this trial suggest sensor-monitored rescue inhaler use can provide the objective data physicians require. Rather than relying on recall data, provider dashboards illustrate real-time, objective summary data on their patient panel.

DISCLOSURE: David Van Sickle: Shareholder: DVS is a shareholder and officer in a company (Reciprocal Labs Corporation) that is developing an electronic inhaler sensor for commercial use. The company did not participate in this research study or finance this manuscript in any way. This does not alter the authors' adherence to all the CHEST policies on sharing data and materials., Employee: DVS is a shareholder and officer in a company (Reciprocal Labs Corporation) that is developing an electronic inhaler sensor for commercial use. The company did not participate in this research study or finance this manuscript in any way. This does not alter the authors' adherence to all the CHEST policies on sharing data and materials. The following authors have nothing to disclose: Rajan Merchant, Rubina Inamdar, Robert Quade, Matt Maenner, Michael Patmas

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Chest. 2013;144(4_MeetingAbstracts):72A. doi:10.1378/chest.1676636

SESSION TITLE: Asthma Diagnosis & Evaluation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PM

PURPOSE: To determine the predictors of poor asthma control and the proportion of poorly-controlled asthmatics receiving controller medications using the Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-Back Survey (ACBS) 2009.

METHODS: The BRFSS-ACBS 2009 for adults was analyzed to determine whether poor asthma control (symptoms, exacerbation, emergency department (ED)/urgent care visits) was associated with demographics, asthma management education, immunization, and inhaled corticosteroid use.

RESULTS: One-third of asthmatics had poor asthma control. Thirty-eight percent had an exacerbation while 9% had visited an ED/urgent care center for uncontrolled symptoms in the past 12 months. Women were 1.794 (95%CI=1.665-1.933) times more likely than men to have an asthma attack and 1.854 (95%CI=1.616-2.126) times more likely to visit an ED/urgent care center during the past year. Patients who were ever taught to recognize early signs or symptoms of asthma were more likely to have good symptom control [p=.016], less likely to have suffered an asthma attack during the past 12 months [p<.001], and less likely to have had an ED/urgent care visit during the past year [p<.001]. Influenza vaccination during the past year was significantly associated with a reduction in asthma attacks [p=.005] and ED/urgent care visits during the past year [p=.001]. Pneumococcal vaccination was associated with significant improvement in symptom control [p=.042], asthma attacks [p<.001] and ED/urgent care visits [p<.001] in the past year. Of the 150 asthmatics with poor symptom control, only half of them used an inhaled corticosteroid medication. Inhaled corticosteroid use appeared to be associated with a significantly lower number of ED /urgent care visits during the past year [p<.0001].

CONCLUSIONS: Although more than a third of asthmatics suffered from poor symptom control and exacerbations and almost a tenth required emergency or urgent care visit/s during the past 12 months, only half of poorly controlled asthmatics were on inhaled corticosteroids.

CLINICAL IMPLICATIONS: Intensification of guideline-based of patients and their health care providers may reduce prevalence of poor asthma control and incidence of ED/urgent care visits.

DISCLOSURE: The following authors have nothing to disclose: Joseph Espiritu

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Chest. 2013;144(4_MeetingAbstracts):73A. doi:10.1378/chest.1659444

SESSION TITLE: Asthma Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Asthma and obesity are a significant public health concern and the prevalence of both is on the rise. Epidemiological data has linked obesity with an increased risk for developing asthma. The relationship of bronchial hyperresponsiveness to methacholine in obesity is unclear. We examined the relationship of body mass index (BMI) with airway hyperresponsiveness in methacholine challenge testing.

METHODS: We conducted a retrospective study over a period of two years from January 1, 2009 to December 31, 2010. The patients had experienced asthma symptoms but had a ratio of forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity (FVC) of > 70%. Airway hyperresponsiveness was assessed by concentration of methacholine needed to cause a 20% decrease in FEV1 (PC20). The cohort included 42 patients. This cohort was then divided based on BMI into two categories: non-obese (BMI < 30) and obese (BMI ≥ 30).

RESULTS: There were 19 obese patients and 24 non-obese patients. There were 15 males and 27 females. A significant difference was observed for FEV1 change on methacholine challenge (Non-obese 10.4 [±6.9], Obese 15.7 [±8.5], p = 0.0308 with Mann Whitney Test). The odds ratio for airway hyperresponsiveness with obesity was 4.86 (95% Confidence Interval 1.30 to 18.13); p = 0.0277.

CONCLUSIONS: In this study obesity appears to be associated with demonstration of airway hyperresponsiveness to methacholine. The exact mechanism by which obesity and asthma are associated remains a topic of further research.

CLINICAL IMPLICATIONS: This data continues to suggest a relationship with asthma and obesity. Future research may show that weight loss has an impact on improving airway hyperresponsiveness.

DISCLOSURE: The following authors have nothing to disclose: Nader Mahmood, Ayham Aboeed, Suresh Kumar Manickavel, M. Khan

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Chest. 2013;144(4_MeetingAbstracts):74A. doi:10.1378/chest.1704632

SESSION TITLE: Asthma Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Asthma is a common diagnosis, but may be mimicked by a number of uncommon conditions which can only be diagnosed with a lung biopsy.

METHODS: We looked retrospectively at patients referred to our Center in the last 5 years with refractory asthma or asthma-like symptoms who underwent VATS lung biopsy for ultimate diagnosis, after excluding vocal cord dysfunction.

RESULTS: 19 of 22 were females, with an average age of 54. Prior to biopsy, 10/22 demonstrated restrictive physiology, 3/22 were obstructed, 5/22 showed both obstruction and restriction and 4/22 patients had normal spirometry. 10/22 showed bronchodilator responsiveness, including 4/10 with restrictive physiology. Thin section, high-resolution, non-contrast CT scans revealed relevant abnormalities in all 22 patients including, air-trapping (expiratory view only), ground-glass infiltrates, tree-in-bud pattern or bronchiectasis. Of the 22 VATS procedures performed, the most common diagnosis was either constrictive/obliterative bronchiolitis (9), or hypersensitivity pneumonia (5),followed by follicular bronchiolitis (2), and eosinophilic pneumonia (2). One biopsy showed asthmatic granulomatosis, one sarcoid, one eosinophilic granuloma and only one biopsy revealed airways disease compatible with asthma. Predisposing causes included suspected reflux (14/22) or bird exposure (6/22). 9 of 20 patients responded to therapy, often involving immunosuppressives; 4/20 remained stable.

CONCLUSIONS: A number of respiratory diagnoses can either mimic or accompany athma which may require different therapies and pursue a different natural history than asthma.

CLINICAL IMPLICATIONS: Failure of patients to respond to appropriate interventions to control asthma with trigger assessment, environmental control and step therapy should raise the clinical suspicion that additional/alternative diagnoses may be present which require VATS for confimation but which can respond to therapy.

DISCLOSURE: The following authors have nothing to disclose: Mark Millard, Sandra Dunn, Grace Hernandez, Laura Blundell, Zlatko Prijic

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Chest. 2013;144(4_MeetingAbstracts):75A. doi:10.1378/chest.1698492

SESSION TITLE: Asthma Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Tiotropium bromide, a long-acting anticholinergic agent, has been proven to benefit some patients with nocturnal asthma, uncontrolled asthma, and chronic obstructive pulmonary diseases. The American Thoracic Society guidelines for the Methacholine Challenge Test (MCT;1999 recommend that tiotropium bromide be withheld at least 48 hours, perhaps as long as a week but a definite period has not been clarified. The authors aimed to investigate the effect of tiotropium bromide on methacholine-induced bronchoconstriction after 72 hours in patients with asthma.

METHODS: Patients with asthma-associated symptoms, but with normal spirometry results, were prospectively enrolled between January and November 2012 at Phramongkutklao Hospital. The MCT was administered with these patients. If the MCT result was positive, a single, inhaled 18 microgram tiotropium bromide was prescribed and a further MCT was scheduled after 72 hours to re-evaluate the MCT result.

RESULTS: Of 25 patients with positive MCT results 18 completed the 72 hour MCT re-evaluation test. All patients were male, with a mean age of 21.17 (SD=1.38). For 10 patients (55.56%) the MCT result changed from positive to negative, the remaining 8 patients (45.44%) maintained positive results (p<0.001). The median PC20 (IQR) in the negative group was 5.79 mg/ml (5.03-6.90), in the positive group it was 0.52 (0.27-3.06) mg/ml (p<0.001).

CONCLUSIONS: Tiotropium bromide should be withheld at least 72 hours before administering the MCT. This is especially the case with mild bronchial hypersensitive patients.

CLINICAL IMPLICATIONS: Tiotropium has been shown to improve FEV1 and to decrease the exacerbation rate with asthma patients. It is likely to be increasingly used for this purpose. The use of the Methacholine challenge test (MCT), after asthma symptoms have been controlled, has been recommended to evaluate bronchial hyper-responsiveness and to confirm that the inflammation is in remission. The results of the MCT are then used to determine the appropriate step down therapy. Our research has provided information that can be used to determine how long the tiotropium should be discontinued before administering the MCT.

DISCLOSURE: The following authors have nothing to disclose: Pattarin Pirompanich, Amornchai Lertamornpong

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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543