Dharani Kumari Narendra

Update in Management of Severe Hypoxemic Respiratory Failure

&NA; Mortality related to severe‐moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao2/Fio2 < 150 mm Hg (ie, severe‐moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H2O, and initial positive end‐expiratory pressure (PEEP) of 10 to 12 cm H2O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H2O and driving pressure does not increase. A fluid‐restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao2/Fio2 < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.

Bilateral pneumothorax after bronchoscopy without biopsy--a rare complication: case presentation and literature review.

Bronchoscopy and bronchoalveolar lavage (BAL) are widely accepted diagnostic procedures in various pulmonary etiologies. Complications of bronchoscopy are relatively infrequent and most often minor, namely, bleeding and infection. Pneumothorax is a rare complication of bronchoscopy with transbronchial biopsy. Bilateral pneumothorax developing after BAL without biopsy has been rarely described in the literature. A 51-year-old woman presented with symptoms suggestive of reactive airway syndrome and underwent bronchoscopy with BAL to rule out vocal cord paralysis and to investigate other potential causes of her symptoms. Immediately after BAL, she developed bilateral pneumothorax requiring chest tube placement. The pneumothorax was resolved with the chest tube and the patient recovered. However, the etiology of the pneumothorax remained unclear. We presume that cough-related increase in intrathoracic pressure might have led to interstitial air dissection and bilateral pneumothorax.

Ectopic Thymoma- Presenting as a Large Pleural Mass

Thymoma is the most common neoplasm of the anterior mediastinum. Patients may be asymptomatic or present with symptoms of local compression, myasthenia gravis or other paraneoplastic syndrome. We present case of a middle aged woman with a large pleural based mass who was relatively asymptomatic Biopsy of the mass revealed thymoma type AB.Work up showed that she has multiple abdominal masses etiology of which is not known. Whenever feasible, surgery is the treatment of choice for thymoma.Our patient is undergoing chemotherapy with the goal that once the tumor size is reduced she will be able to undergo surgery.

555: AGGRESSIVE LYMPHOMA IN A CRITICALLY ILL PREGNANT PATIENT

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Natural Killer (NK) and T cell lymphomas are rare subtypes of lymphoma, traditionally difficult to treat and usually have poor prognosis especially in late stage disease. We present a case of acute respiratory distress syndrome (ARDS) and multiorgan failure due to aggressive atypical NK/T cell lymphoma in a pregnant patient. Methods: 34 year-old Middle Eastern woman with a history of Hodgkin’s lymphoma 10 years ago with remission, tuberculous adenitis treated 9 years ago, and T cell lymphoma 1 year ago, resistant to chemotherapy and evidence of disease progression on PET scan, primigravida presented at 17 weeks gestation with progressive shortness of breath and left upper extremity swelling, pain and gangrenous digits. She had worsening hypoxia and ARDS requiring mechanical ventilation. Computerized Tomography of chest revealed multiple lung masses. Her left arm was swollen, infiltrated with tumor, hemorrhage, and infection, therefore underwent radical resection with forequarter amputation. Sputum cultures grew multiple drug resistant organisms and was on multiple broadspectrum antibiotics. We faced diagnostic challenges of tuberculosis versus lymphoma as her cervical lymph node biopsy revealed caseating and non-caseating granulomas and bone marrow flow cytometry was not suggestive of lymphoma. Pathological sections of the left arm showed extensive involvement with aggressive Epstein Barr Virus (EBV) negative T/NK cell lymphoma and was finally started on half dose of etoposide, steroid, cytarabine and cisplatin (ESHAP) therapy during pregnancy. Multi-disciplinary team discussions were held to assess risks and benefits for the mother and fetus. Due to potential fetal toxicity with category X and D agents, decision was made to deliver the baby at 30 weeks followed by optimal chemotherapy. Unfortunately, the patient developed neutropenic sepsis and refractory septic shock leading to her death 3.5 weeks postpartum. Results: This is a challenging case of a critically ill pregnant patient with aggressive T/NK cell lymphoma. There are few case reports of NK cell lymphoma with lung involvement. T/NK lymphomas are almost always EBV positive. EBV negative status in our patient makes this an extremely rare case. Management of aggressive lymphoma in pregnancy requires multidisciplinary approach. NK/T cell lymphoma involving lung leading to acute respiratory failure and septic shock is rare.

Procalcitonin in Chronic Obstructive Pulmonary Disease Exacerbations: Is It Ready for Primetime Use?

Exacerbations of chronic obstructive pulmonary disease (COPD) impose a major burden on patients, their caregivers, and the healthcare system. The diagnosis of COPD exacerbation is traditionally based on clinical symptoms, as there are no known objective physiological or radiological measures that can confirm the diagnosis. The Global Initiative for Chronic Obstructive Lung disease (GOLD) (1) guidelines recommend antibiotics in severe exacerbations and in those with increased sputum purulence. Antibiotics have been shown to shorten recovery time and reduce risk for early relapse, treatment failure, and hospitalization duration (1). Although bacterial infections are common triggers for a COPD exacerbation, other triggers to be considered include viral infections, exposure to noxious stimuli, and poor compliance with maintenance medications. In addition, certain disease conditions such as acute congestive heart failure and pulmonary embolism are often confused with a COPD exacerbation because of overlapping symptoms. Therefore, the diagnosis of COPD exacerbation and its trigger or triggers, and thus the choice of therapy, may be challenging for some clinicians. Our better understanding of the underlying pathophysiology and inherent need for more accurate diagnosis and treatment of COPD have led to the exploration of improved reproducible diagnostic tests. Biomarkers or “biological markers” are measurable indicators of some biologic state or condition and are most often measured in biologic fluids such as blood, sputum, or urine, or in exhaled breath. A biomarker is defined as a “characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (2). An ideal biomarker in COPD exacerbation should be easily measured, cost-effective, reproducible, and able to differentiate stable disease from exacerbation. Furthermore, an ideal biomarker should have prognostic and predictive features (3). A systematic review article (4) revealed 59 studies that evaluated the biomarkers in COPD. Biomarkers that have been examined include exhaled nitric oxide and volatile organic compounds; sputum: elastase, interleukin (IL)-8, leukotriene B-4, myeloperoxidase, eosinophilic cationic protein, IL-6, tumor necrosis factor-a; bronchoalveolar lavage: eosinophilic cationic protein, IL-6, IL-8, myeloperoxidase, tryptase; and serum procalcitonin (PCT), fibrinogen, blood natriuretic peptide, and C-reactive protein. Unfortunately, none of these biomarkers thus far has consistently been shown to be an ideal representative for COPD exacerbation (4). PCT is a 116-amino acid precursor of calcitonin, which increases in response to bacterial infection, but remains low in nonbacterial infection or inflammation. As bacterial infections are important triggers of COPD exacerbations, serum PCT has emerged as a potential biomarker to identify patients who need antibiotic therapy of their COPD exacerbation. PCT has been studied extensively in several infection-driven disorders such as pneumonia and sepsis, as both a diagnostic and a predictive biomarker. However, its role in COPD remains speculative at best. Previous randomized controlled trials and metaanalyses suggested that the use of PCT as a predictor of a bacterial etiology of a COPD exacerbation may lead to a significant reduction of use and duration of antibiotic in treatment (5–9). However, most of these studies included a small sample size and were single-center studies. The aim of the study in this issue of the AnnalsATS by Lindenauer and colleagues (pp. 1779–1785) was to determine the effect of in-hospital PCT testing on the decision to initiate antibiotics and on treatment duration for patients hospitalized with exacerbation of COPD in a large cohort of patients obtained from premier healthcare alliance data (10). The investigators performed a series of cross-sectional and longitudinal data analyses on 203,177 hospitalized patients with COPD exacerbation at 505 hospitals in the United States. A total of 180,958 patients (89%) were treated with antibiotics during hospitalization. A total of 10,377 (5%) of the patients were tested for PCT during their hospitalization. Even though high PCT-adopting hospitals had a 40% increase in PCT testing between the periods of 2009–2011 and 2013–2014, no difference in rate-adjusted antibiotic treatment rate or mean duration of antibiotic treatment was noted between these two periods. The study concluded that procalcitonin testing had a weak association for antibiotic initiation and no effect on duration of antibiotic therapy among patients hospitalized with exacerbations of COPD. The major strengths of this study are its inclusion of a large and diverse sample size of patients with COPD exacerbation and the multicenter involvement and exclusion of

1763: AN UNUSUAL CASE OF DRUG-RESISTANT ECTHYMA GANGRENOSUM

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) shock, acute respiratory distress syndrome, and renal failure developed B. cepacia bacteremia and sepsis. Infection persisted despite meropenem and replacement of central lines, and she died May 9. Results: On June 24, the CDC recommended liquid docusate be discontinued in all hospitals. The time lag between our first case of B. cepacia and recognition of docusate as the source of infection potentially contributed to avoidable morbidity and mortality. Any diagnosis of B. cepacia in non-CF patients should prompt an immediate investigation into sources of infection including iatrogenic causes and the possibility of contaminated medication.