Thank you, Dr. Schwalk. Good morning, everybody. I'm very excited to present this case to you. This is the largest post-COVID lung abscess the world has seen, according to the literature. So here we go. My name is Dr. Al-Hayli. I'm a fellow at Maine Medical Center in Portland, Maine. My co-authors are Charlotte Christ, a medical student, and Megan Moore, who's a faculty member. So the main objectives for this session are to discuss the definition of a giant lung abscess, briefly go over the review of the literature, and discuss using a method that we use to rapidly evacuate the giant abscess in this case. So here is the case history. We had a 51-year-old male who came to the ED late December 2021. His only complaints were a right rib pain and a cough. Past medical history, only significant for diet-controlled type 2 diabetes, otherwise healthy. He was unvaccinated. He was hospitalized two weeks prior to this current presentation. He had severe COVID. He was intubated, ventilated for 10 days, treated with the usual cocktail of things, IV antibiotics, steroids, rebdesivir, and tocilizumab. He recovered pretty well, and he had an X-ray, which was reassuring. That was about a week prior to his discharge, and he left sort of mid-December without antibiotics. So that was his prior hospitalization before coming back to the hospital this time. So just to summarize his course, he was in hospital for two weeks. He was initially transferred from a smaller hospital to the big hospital, and then he was home for two weeks, and then he came to the ED. Vitals this time around were normal except for mild tachycardia. His labs, a little bit of leukocytosis with left shift. So this was the last X-ray we had from the prior hospitalization when he had severe COVID. So early December. You know, there's nothing there that suggests there is any abscess in his lungs. But look 25 days later when he represented, he has this development of this structure here in his right lung. So developed rather quickly, I would say, for something of this size. Initial CT scan, when he came this time around, you can see this thing is really large. It actually measured 15 by 12 by 19 centimeters. It was occupying the majority of his right lung. So as we always do, start them on broad-spectrum antibiotics. But you know, we've never seen something like this. So where do we go from here? Being a first-year fellow at the time, obviously I turn to the books and ask for help. So here's a rapid review of giant lung abscesses. The definition, this is back from 1978, and it hasn't really changed. It's any lung abscess greater than four centimeters in size. And these can really mimic empyema, and they tend to be polymicrobial. And there have been several case reports of people sticking chest tubes into these things thinking they are empyemas, and they turn out to be a lung abscess. I will convince you that these are associated with a lot of morbidity, long hospital length of stay, and in some cases mortality as well. So the treatment in general, obviously antibiotic therapy and percutaneous tube drainage, also known as PTD, has superseded surgical intervention over the years because it's thought to be the lesser evil, right? We all know surgery is associated with a lot of complications. But giant lung abscesses are rare post-COVID-19, and thus far there have been only six reported cases in the literature. So what did we do for our patient? So we had multidisciplinary discussions with IR and thoracic surgery, and we proceeded with the placement of a 10 French chest tube by IR. It did take some encouragement because, you know, as you can imagine, nobody gets excited about putting a chest tube into the lung parenchyma, but they obliged kindly and did a great job. But really wasn't draining much, so it had to be upsized to a 14 French, and in spite of that being on wall suction, it really didn't drain very much, maximum 200 ml over the five days, and it was a polymicrobial infection, as you can imagine, which seems to be the case in these things. So looking back at other cases, so here's a table of non-giant lung abscesses, so less than four centimeter undisclosed. On the left column you have the authors and the year, and then the size, which I arranged by descending size order. And then what interventions in addition to antibiotics, and then the hospital length of stay, and the outcome, you would, you know, it's undisclosed where they didn't mention. So I just wanted to show you this table, that even smaller non-giant lung abscesses can have significant complications, morbidity and mortality, and long hospital length of stay. Somebody died, somebody ended up on a home vent. Bucot had a case series of sick ICU patients, COVID ICU, and their mortality was pretty high, which is not unexpected. So kind of a heterogeneous mix of cases. But let's go to the giant post-COVID lung abscesses. So the next biggest case we've seen was 10 by 8 by 8, and this patient ended up with a complete right pneumonectomy, and most likely died, because it was a mucomycosis case, and we know mortality there is close to 100%. But even if you look down at smaller abscesses, some of them can have significant length of hospital stay. And at the time when we had this patient, beds were really tight. I mean, we had patients in the corridors, and the ED was boarding patients. So there were many reasons to try to sort of move things along quickly. And here's our case, which was 15 by 12 by 19. So we used chest tube drainage with manual syringe aspiration, and I'll show you what that looks like. And that was like a one-and-done procedure. Length of stay was the shortest in those cases, 14 days. So we have the materials that we need, which is a three-way stopcock. We have some flushes. We have a 50-ml syringe, some alcohol wipes, and a waste container. Attach our 50-ml syringe, and then unlock it away from the patient, and we're going to use some gentle suction on the syringe. As you can see, pus can be very thick, and it's difficult to get out sometimes. As you can see, we did not get much out with this aspiration attempt, so we will lock it towards the patient so we don't entrain any air. We will obtain 10-ml flush, clean with alcohol, attach your syringe, and then unlock it towards the patient. So we go to gently flush, and then we'll do some irrigation, flush and pull, so that loosens up the thick fluid, and we'll try again with the 50-ml syringe. Ideally, your patient should be monitored with telemetry just in case there are any unanticipated events. So you see now the fluid is drained easily, but then it starts to get thick again. You can either try to do some gentle irrigation with what you have in the syringe, just to break things up, and if that doesn't work, we will repeat the flush step. Okay, you get the idea. I'm going to move on. If you want to see the full video, I left a QR code there and you can watch the whole thing. So hopefully nobody's eating. This is the pus that we got. It was at least 800-ml. This was the bigger of the containers. And we also got some air out. That was the point when I got really nervous. I was like, uh-oh, did I pop something and is this air coming from the lung? But you know, there was an air fluid level so it worked out fine. So just some comparisons quickly. So the top, the red line, is the baseline before we did anything to the patient. And then the lower row is after we put the chest tube to suction. So some improvement, but really not great. The patient was not satisfied. He was like, I'm going to be here for weeks. I really don't want to do this. Can you do something else? So this compares after wall suction versus manual aspiration. You can see the thing almost completely resolved. And this is a comparison of baseline before we did anything, and this is after the manual aspiration. So in summary, you know, giant lung abscesses, hopefully I convinced you, they require prompt, swift intervention. You need to achieve source control, reduce the risk of antibiotic failure, avoid surgery and complications like a fistula, and reduce hospital length of stay. In this case, it was safe and effective. But you know, that's my N of 1, so I don't claim to be an expert, but here we are. I'd like to thank my co-authors and Paul White for doing a great job with the video. And here are some references. Thank you. »» Does anyone in the audience have a question? I just have one question. Ahead of time, before doing this procedure, did you have anything in your mind that, oh, if this happens, we'll stop? Anything in particular? »» Yes. So pain. We had the patients monitored as well, so like any DSADS or sudden tachycardia. We didn't know what could happen, but we tried to take every precaution. And certainly there was a lot of shared decision making with the patient, you know, full disclosure, we've not done this before, but do you want to get out of here really soon? And you know, I can offer you this. We'll see how it goes. And he was actually very excited. He took pictures and sent them to his wife. »» Well, it worked out. Thank you. »» Thank you. »» Sure. »» Did you try like TPA on dornis? Is it indicated for this case? »» Very briefly crossed my mind. But putting TPA dornis into the lung parenchyma just didn't seem like it would be a good idea. Even thought about using like a saline irrigation, like according to the PET trial. But again, we're infusing sort of a decent amount of fluid into a contained space. So I didn't want to like rupture the thing. So yes, briefly crossed my mind, but just didn't feel safe. I wonder if anybody thinks differently. But yeah. »» You know, I think sometimes the CF like specialists may use dornis in the airway to help with thick mucus. So maybe you could have done that without the TPA. But I've never personally done that. So I don't know. »» Great question. Thank you. »» Thank you. Okay. And then we have someone filling in for our next speaker, Dr. Flora will be talking about a Veteran's Hospital Early Experience with Transbronchial Lymph Node Cryobiopsy for Dr. Keir. »» Thank you. I'm presenting on behalf of Dr. Nikki Keir, who is my fellow, I'm an interventional pulmonologist at the Memphis VA Medical Center. I have nothing to disclose. Just quickly going to go through a little bit of background about EBLS and neoplastic processes as well as benign processes. The two case reports that were part of the abstract but then also go into all the additional cases I've done since. I still have several other cases which I just didn't include on this. So just in the age of precision oncology, there's an increased need for intact and larger tissue samples from a pathological genomic and molecular as well as immunological assessments. When you're looking at the pooled adequacy from meta-analyses for next-gen sequencing, it's about 86.5% for EBLS. For PD-L1 the adequacy is 86%. However, when we start looking into lymphoma, the overall sensitivity is only about 66% while the specificity is 99%. But the pooled adequacy for ancillary testing is as low as 63%, 64%. And then 33% of cases have insufficient histopathological characterization because it is cytology. So actually, I took out the benign stuff. On our first patient, a 63-year-old Caucasian male post-Vietnam veteran, history of combined small cell carcinoma, status post right upper lobe lobectomy. He was noted to have increasing right hyaluronate and sub-cranial lymphadenopathy on his post-curative intense surveillance imaging. A PET CT noted a station 10R lymph node with an SUV of 4.8. He underwent EBLS TBNA by another provider. However, the lesion in question was never biopsied and the other stations were non-diagnostic. And the second patient, a 75-year-old Caucasian male Vietnam veteran with a history of stage 1A squamous cell carcinoma, status post right upper lobe wedge resection with clear margins. Post-imaging was showing a right hyaluronate mass nine months later. It was a PET AVID SUV of 5, right hyaluronate lymph node. Again, underwent an EBLS TBNA by another provider, which was non-diagnostic and all stations biopsied. And so that also necessitated repeat bronchoscopy. So I performed EBLS cryo on both of these patients. Basically a standard of care EBLS survey was performed. I did these cases under endotracheal intubation and general anesthesia. We were just using standard of care Olympus VisiShot 1, 22-gauge, and Olympus VisiShot 2, 21-gauge needles, at least on these cases. The literature describes the use of using 19-gauge needles in these cases, and I did have access to rows. After the TBNA, multiple punctures were made at the same site with the 21-gauge EBLS needle to create a larger track through the bronchus into the target legion. The literature also describes using a small incision via a high-frequency needle knife or using a YAG laser. Then I used an Irby 1.1-millimeter cryoprobe that was advanced through this tract with appropriate positioning seen on ultrasound, used a greater than three-second freezing time, and then I removed the specimen, the probe, the scope, and block. The literature describes anywhere between three to seven seconds of cooling time with removal of the specimen. With these new disposable cryoprobes, they do thaw very quickly, so as I'm pulling out and block, I'm also continuing to freeze for an additional second as I'm removing the specimen and the scope. Then I would thaw the specimen in formalin, then wash the probe in saline before removing it through the working channel so I don't contaminate the airway. So when you take a look at imaging on ultrasound, you can see the ice ball forming on ultrasound. You can see the size of the gross tissue when you remove everything and block, and then in formalin you can see the size of all these specimens. I took about eight specimens from here, so it's really sufficient tissue. So in this first patient, you can actually take a look at the imaging of the cell block on low power and medium power versus the low power cryo-EBUS section and the medium power. Clearly you can see that there's preservation of the tissue architecture as well as a significant amount of tissue. With the help of our pathologist who graded the quantity and quality, you can see that at least on these ones there's marginal cellularity, marginal quality, and marginal cellularity for molecular testing adequacy from the cell block, but when you look at the cryoprobe everything was adequate. You can also see that the size of the tissue was significantly larger as well. And then the same thing on the second patient. This one is very clear on the slides that you can see the amount of tissue. They were quite inadequate using the needle alone, but with the cryo-EBUS everything was adequate. And so just looking at the literature, there was a randomized study of 197 patients doing TBNA first versus cryobiopsy first. The overall diagnostic yield for TBNA was 80%, but it was 92% for the cryobiopsy and that was statistically significant. The diagnostic yields were similar for metastatic lymphadenopathy, but the cryobiopsy was more sensitive for uncommon tumors as well as benign disorders. In terms of complications, there was two cases of pneumothoraces and one case of a pneumomediastinum. And then looking at a systematic review of seven studies of 555 patients, when you're looking at the overall usefulness, EBUS-TBNA, 92% versus 80%, sorry, cryo-EBUS was 92% versus 80% for EBUS-TBNA. The benefit really came in when it came in with lymphoma as well as benign disease. So these are just information from my own patients, 10 cases, 12 lymph nodes. This is just the background when you look at the diagnostic yield of EBUS-TBNA was 100%. Looking at the diagnostic yield of cryo-EBUS was also 100%, but where the difference came in was more so in terms of the adequacy. So I was able to get an answer using the needle. So when you need an answer, you don't really need to do a cryo-EBUS, but when you're trying to get more tissue, that's where cryo-EBUS comes in with more benefit. Now coming into the benign diagnoses, I had five cases. Looking at rose positivity for lymphocytes was as low as 42.9%. The final pathology with EBUS-TBNA were three anthracotic lymph nodes, one sinus histiocytes, and the one non-necrotizing granulomas, and two were non-diagnostic. But then using cryo-EBUS, I was actually able to get more detailed information on the pathology. Four were diagnosed with sarcoidosis with non-necrotizing granulomas. The one with the sinus histiocytes was consistent. One was with fibrotic scarring, so that was one of the non-diagnostic, and then the other one was still continued to be non-diagnostic. In terms of complications, I only had complications with benign disease, with pneumomediastinum, because I had to use a significant number of passes to create the tract. But the biggest issue I found with these benign cases is that you have a lot of fibrotic lymph nodes, especially with burnt-out sarcoid. You also have fibrosis of the airway as well, so it's very hard to pass that 1.1-millimeter cryoprobe. So I think that's what caused that one non-diagnostic case. Finally, just I wanted to throw this in here, I did a transesophageal cryopsy. That has its own issues, which I don't recommend anybody really doing. And then I think I didn't include, there may be, sorry. These are two cases of doing transtracheal cryobiopsies for peripheral lesions. And so one of the biggest issues here is that you're pushing away at the visceral pleura, so you're pushing, it's very hard to actually get through the airway, through the pleura, pleural space, both of the pleura, then into the parenchyma. So that's something I'm still working on, in terms of the technique. So that's the conclusion. So cryo-EBUS improves tissue adequacy for molecular testing, however, it doesn't necessarily improve diagnostic yield compared to E-BUS TBNA. The majority of our malignant cases in our series were previously non-diagnostic attempts from other providers within the same institution, so I really don't know what the issue is with that and how that really makes a difference in my particular data. Cryo-EBUS is superior to E-BUS TBNA when diagnosing benign pathology. However, the track creation is difficult for upper lobe nodules, because of the difficulty of passing the probe through the bronchial wall pleura and parenchyma, there might need to be some improvement in technique. And then for E-USB, for transesophageal cryobiopsy, it was only experimental because that was the only way I could diagnose the cancer in the patient, and I wouldn't recommend anybody doing it until more cases and more information is out. Thank you. Does anyone in the audience have any questions? Yeah, just come up to the microphone. We have time for one question. Is that the one? Yeah. Okay. All right. Here you go. Okay. All right. I feel like we should clap. Thank you. Yes. All right. Good morning. Thank you. All right. So, I'm Andrea Ramirez. I'm a pulmonary critical care fellow at LSU in Shreveport. I'll be presenting a case series of ECMO use for advanced pulmonary procedures, and I have no disclosures. So, this is going to be a case series that supports the use of short-term VV ECMO in patients with acute hypoxic respiratory failure that are requiring advanced bronchoscopic procedures. So, the first case is a 44-year-old male who had no significant past medical history, and he was admitted for pharyngeal abscess with airway compromise. At the time of his presentation, he was evaluated by ENT, and he had significant pharyngeal edema and underwent awake nasal intubation and was admitted to the ICU. The chest x-ray on the right is from the time of his admission, and really, he had minimal ventilator settings until hospital day six. That's when he started to develop a significant increase in oxygen requirements, and his repeat chest x-ray, which is shown on the right, sorry, was significant for pneumothorax and worsening opacities. A chest tube was placed at that time, but his lung did not re-expand and had a persistent air leak. On hospital day eight, his hypoxia continued to worsen, and therefore, with our multidisciplinary discussion, it was determined that the patient would benefit from being off positive pressure ventilation and have endobronchial valves placed, and this would be safely achieved with the support of ECMO, and he was therefore cannulated on hospital day eight. The chest x-ray on the far left is from the time of his cannulation. When he was cannulated, he was actually placed straight onto teepees, and a surgical chest tube was placed. So that is on the chest x-ray in the middle, and he had re-expansion of his lung, but he continued to have persistent air leak and significant support from ECMO. So the following day, endobronchial valves were placed, and that is the chest x-ray on the far right, and his air leak did resolve at that time, and he continued to improve post-procedure, and was subsequently weaned off of ECMO support after 10 days, and this is the chest x-ray on the left is from the time of his discharge. His endobronchial valves were removed about two months later, and this is his most recent chest x-ray here on the right. The second case is a 61-year-old female. She had a medical history significant for AML in 2001, but that wasn't remission, but her recent bone marrow biopsy was concerning for possible reoccurrence. She presented as a transfer from outside hospital for acute hypoxic respiratory failure, secondary to pulmonary alveolar prognosis, and she was transferred to us for whole lung lavage. At her time of her admission, she was on comfort flow, 40 liters, 60%, and this was her CT. She successfully underwent a right whole lung lavage, but when the left was attempted, she became hypoxic. Bradycardia had severe hypotension. This procedure was quickly aborted. ABG drawn at that time did show severe respiratory acidosis. So given the complexity in her hemodynamically, how she became hemodynamically unstable, we determined that to safely proceed with left whole lung lavage, we would, she would require ECMO support. So she was cannulated, and this chest x-ray on the left is from the time of her cannulation. She, we proceeded with left whole lung lavage, and you can see her whole, that's from her left whole lung lavage, and a repeat of the right. And then that is her chest x-ray post-procedure. She had improvement in her lung compliance and oxygenation. She was decannulated from ECMO on day, after three days, and liberated from mechanical inhalation as well after three days. And then our third case is a 72-year-old female. She had a medical history significant for COPD. She was admitted for acute hypoxic respiratory failure, secondary to a right pneumothorax. So when EMS, she was evaluated by EMS, they intubated her for respiratory distress, and when she arrived to the emergency department is when they discovered her right pneumothorax, and a chest tube was placed, and she had appropriate re-expansion of that right lung. She was extubated on hospital day two. On hospital day four, her right chest tube was inadvertently removed, and had reoccurrence of her right pneumothorax, and therefore another chest tube had to be placed. Shortly after that chest tube was placed, she became hemodynamically unstable due to a left tension pneumothorax that was decompressed, and a chest tube was placed. She also required to be re-intubated at that time. And she was intubated with a 7-0 ET tube, and this is her chest x-ray post-procedure. She, after her, she stabilized, she had a persistent right air leak, and this is, appreciate it here. I appreciate it here. And since she continued to have significant hypoxia, and wouldn't require an ET tube change if we were to place endobronchial valves, we decided to proceed with ECMO supports to change her ET tube and place endobronchial valves. And so she had valves placed, and was extubated post-procedure. Her air leak resolved, her pneumothorax did not reoccur, but, and her ECMO support, and her ECMO support was able to be weaned. She had a total of a 14-day run, but she failed her trial off of ECMO support, and since she had already been on ECMO for two weeks and her age, the family ultimately decided to proceed comfort care. So, as patients seen in our case series, requiring advanced bronchoscopy, requiring advanced bronchoscopic procedures, they can pose difficult obstacles in procedural planning due to the acuity of their clinical presentation related to their underlying pulmonary pathology. There currently, there's case reports that do support the use of short-term VV-ECMO to support patients. This is seen in the setting of central airway obstruction, mostly things such as stenosis, malignancy, and hemoptysis. And these case reports did have limited associated morbidity. This was a case series where we used short-term VV-ECMO in patients with acute hypoxic respiratory failure that required advanced procedures for treatment, in patients who otherwise would not have been able to undergo bronchoscopy. These are our references. Okay, so next I'll introduce Leila Al-Bizri, who'll be talking about innovative use of ARNT bronchial blocker for intermittent control of hemorrhage and left lung protection during tumor debulking in a patient post-pneumonectomy. I really hope this works. All right. Thank you. Thank you, everyone. I know the title is big, but it's quite simple presentation of how we used an ARNT blocker to help us temporize the airway during a procedure to help a patient with his central tumor. So that's the project or like the procedure was done by Dr. Panchabai, and he's one of the IP proceduralists in our hospital, University Hospitals, with the other proceduralists team. So the first learning objectives, we have central airway obstruction as a morbid complication of malignant tracheal lesions, and challenges are there whenever it's also an approach to treat those tumors when the patient has a pneumonectomy history, and we're dealing with only one lung during a procedure where we have to ventilate that lung, and in the same time protect that lung from any bleeding that can go into it. So what Dr. Panchabai decided to do in that scenario is that he wanted to use the ARNT endobronchial blocker to kind of tampon out that bleeding whenever he was trying to debulk the tumor. So early diagnosis of those tumors are important as patients can be candidates for surgery, and the bronchoscopy can help alleviate those obstructive symptoms whenever it's got early, or if the patient is not deemed to be a very good surgical patient. And post-pneumonectomy patients pose a challenge, as we mentioned, because we don't want to have any leak or any blood seep into that one lung that's ventilating the patient. So endobronchial blockers, we use that in our hospital because it's commonly used, and it's from Cook Medical, and usually these blockers were out being used mostly for one lung ventilation in procedures with pneumonectomy, and we've been using them mostly in our ICUs as for massive hemoptysis, and in this case specifically, it was used to temporize the bleeding. So the case presentation, the patient was a 76-year-old man. He had a history of stage two squamous cell carcinoma, and he received chemotherapy and radiation and right pneumonectomy in 2020. So he was getting just surveyed in SCAD scans when they noticed that he has a 1.2 centimeter intertracheal tumor, and a flexible bronchoscopy was done initially and evaluate the tumor, and it was noted to be exophytic, and it was friable in the distal trachea, just before the right main stem take off. So what happened initially in the procedure is that they attempted to do selective like left lung intubation, but that was not successful, especially with the position of where the tumor was. So Dr. Panchabai kind of came with the idea of using the endobronchial blocker to help tamponade while he was debulking the tumor, and that's what the procedure ended up needing, is that whenever he inflated the balloon, that helped tamponade after the debulking, and the outside glottis technique was deployed rather than inside the bronchoscope deployment. And it was being inflated intermittently during the debridement to help with the hemostasis, and APC was being used to kind of help with the debulking. And that kind of helped achieve the airway clearance and debulk the tumor, and the patient tolerated the procedure well and was able to be discharged home. And the patient went along after with the pathology showing the recurrence of the squamous cell, and he received further therapy with his oncologist. So in conclusion, patients who are post-pneumonectomy do pose a challenge, especially when they have central tracheal tumors, as this is a very technical case because you want to try to prevent, as we mentioned, bleeding or any more problems with having issues in that single lung. And innovative use of such tools like the RNDET endobronchial blocker has helped in such a specific situation. Thank you. Definitely because of the protection of the area, but sometimes with a rigid, the central airway is very hard to reach, to reach those procedures. With the rigid? With the rigid, because how the placement is and how the movement. They use the flexible here, I think it's just because of the easier way of deployment of things, so that's why it was used, yeah. Yes, inflation and deflation of the blocker, yes. So I think the Fogarty balloon could have, like it's kind of difficult to use in that situation. But initially the plan was to do this like the single lung ventilation, which like did not work. And in the same time also, ECMO has been used in our hospital to be like as a backup plan if in case things like that happen. But I wasn't there in particular with Dr. Panchabai to see like what, but it was more of like an innovative way to use that to help him out as a backup strategy. You have only one lung to ventilate, so you would simply use the single incubation tube and put it on the... True, but it didn't work, yeah, with them. Like, they tried, but technically it didn't work, like, with... Ah. Yeah, sorry. Yeah, Tanmay was in my class, so I know he's, he trained at a good place, so he does rigid bronchoscopy. I assume there was probably a reason why it wasn't used, because I also had that question, you know, if the rigid bronchoscope was used, because it could also potentially be used to bypass that tumor and tamponade at the same time, but maybe there was difficulty with intubating the same reason, like with the ET2, because of the anatomy post-pneumonectomy, we don't know. Thank you. Thank you so much. Okay, next I'll introduce Mohamed Azam who will be talking about whole lung lavage after lung resection for MUCOR and pulmonary alveolar proteinosis and acute myeloid leukemia treated with stem cell transplant. I'll just go this way. Good morning. Thanks a lot for being here. It's a very long title. I'll be talking about a whole lung lavage as a mechanism for pulmonary ovular proteinosis in a patient that had mu-core development and had acute myeloid leukemia and was treated with a hematopoietic stem cell transplant. As I said, my name's Omer. I'm one of the pulmonary therapeutic fellows at Wellstar MCG is what it's called now in Augusta. Some of the co-authors and participants in the case include Dr. Hoy, who was our interventional pulmonology fellow last year. Dr. Beshara, who is one of our interventional pulmonologists. Dr. Miller, part of the surgical team. And Dr. Islam, who was involved with the case as well. So the lesson objectives include a brief description of PAP, rare fungal infections, as complications of PAP, and management for PAP, including whole lung lavage, especially in patients after they had undergone a wedge resection. PAP is caused by multiple, the underlying reasons are multiple. There's a disruption of the granulocyte macrophage, colony stimulating factor, which includes autoimmune and hereditary PAP, which GMCSF regulates the clearance of surfactant by macrophages. There's also disorders, congenital disorders of surfactant production and secondary PAP, which is a rare condition and is associated with systemic diseases, including autoimmune disease, hematological diseases, inhaled irritants, and is present in significant dust exposures as well. These factors all disrupt the normal functioning of the alveolar macrophages, which reduces the clearance of the surfactant, leading to accumulation of the lipoproteinaceous material in the alveolar space. All pneumoconiosis may lead to PAP-like pathophysiology. PAP itself can lead to increased vulnerability to invasive infections. There have been some case reports presented before for invasive pulmonary aspergillosis after secondary PAP development. So leading to our case, we had a 53-year-old female who had AML, previously transplanted, failed transplant, was on FLAG-IDA regimen, followed by growth colony stimulating factor, and underwent hematopoietic stem cell transplant, again, three months after her initial relapse. Over the next two months after the transplant, she had multiple admissions to the hospitals for respiratory failure, pneumonias, sinusitis. CT scan on one of these admissions was done showing a left upper lobe lesion for which interventional immunology was consulted and underwent a robotic. It was a peripheral lesion as a robotic bronchoscopy was implemented, and transparent biopsies were performed on the left upper lobe lesion, which grew mucor on tissue culture. This time, antifungals were initiated, and CT surgery was consulted as well, and the patient was taken for her left upper lobe white shirt section. Post-surgery, we had hoped that with the antifungal therapy, she would have some improvement in her respiratory status. However, she had continued worsening in her respiratory status, requiring more oxygen, multiple ICU stays. Also, she had multiple CT scans done over a period, over all of the spirit. And we noticed that there was worsening of the parenchymal lung disease, and it appeared like more of a crazy paving pattern, at which time we asked our pathology department to see if a PAS staining could be done on the resected lung, and which confirmed the diagnosis of pulmonary alveolar proteinosis at that time. These are the CT scan over time. Figure 1A, sorry, is the one which showed the left upper lobe necrotic lesion for the first time. At that time, she had already developed significant bilateral parenchymal disease pattern, including what we call a crazy paving pattern. Figure 1B is post-resection, and figure 1C is about a week after the resection with improved aeration. However, it did show worsening bilateral changes. This is the resected lung. And then management-wise for secondary PAP is usually treating the underlying disease, which may treat infections, treating the autoimmune disease, and then just doing supportive therapies for these patients. Whole lung lavage can be used to alleviate symptoms for these patients. However, there have been very limited data in terms of whole lung lavage for patients that had undergone a recent white resection. There have been only two reports previously, and it didn't include the timeline between the wedge resection and the whole lung lavage. However, discussing this with our patient, we did end up taking the patient to the OR for a whole lung lavage at day 17 of the wedge resection to do the whole lung lavage of the right lung with lung ventilation of the left lung. We used low tidal volumes at that time with less than 200 milliliters. We did have to stop multiple times and ventilate both sides. Instilled about 7.2 liters of fluid and got about 6 liters of fluid over 10 cycles. And then on day 51 after surgery, it's moving by itself, sorry. On day 51 after surgery, she underwent another whole lung lavage of the left side this time, 2.7 liters in and about 1.7 liters out. Over 10 cycles. With the whole lung lavage, she did have improvement in her respiratory oxygen requirements. Initially when she had gone in for the right lung, she was on high flow 40 liters. After the procedure, she was able to come down to five liters, nasal canine was discharged home. The whole lung lavage on the left side was done as outpatient where she had come in on just two liters continuous use. She had been followed up in our oncology clinic until about two months after the whole lung lavage of the left side and she was on just two liters with emulation at that time. This is a picture as we could see, started from the, I guess the right side of the screen to the left, one to 10 with decreasing amount of proteinaceous material in each jar. Key points of the case is that it is a very unique presentation of having mucormycosis and PAP secondary to in a patient with AML. Surgery was needed to salvage normal lung function and remove the necrotic left upper lobe lesion and then whole lung lavage was done for symptomatic relief or secondary PAP and it was deemed to be, we did not have any complications after the procedure. We assumed that the lung after western section can tolerate regular tidal volume ventilation. And in conclusion, PAP and fungal infection present together are very rare complications for hematological malignancies, especially after they've received a transplant since they're more immunocompromised. Case demonstrates the safety of initiating whole lung lavage for secondary PAP after western sections have been done and collaboration of different specialties in the hospital for enhanced patient care is very important as well. Thank you all for being here. Good morning everyone, my name is Vivek Bhatt. I'm from the Pulmonary and Sleep Center of Augusta and I'll be presenting the novel use of the Ion Robotic Guided Navigational Bronchoscopy System to manage an antibiotic refractory lung abscess. I have no disclosures. So our patient was a 42-year-old male who presented with complaints of sudden onset cough, shortness of breath, wheezing, and hemoptysis since two weeks. He also reported a little fatigue and about five pounds weight loss. He denied any of the systemic complaints like fever or night sweats. His primary care physician had diagnosed him as pneumonia and given him amoxicillin, azithromycin, ceftriaxone, and inhaled bronchodilators. These were all oral antibiotics. His past medical history was not significant except for a little reflux. So he was referred to our center for further evaluation in view of his non-improving symptoms. So as you can see here, the chest x-ray showed thick-walled five into six centimeter cavitary lung mass with an air fluid level in the posterior superior segment of the right lower lobe. His spirometry and lab investigations were unremarkable and his CT chest confirmed the chest x-ray findings. Given his lack of response to prior antibiotics, we posted him for a robotic navigational bronchoscopy. That's Dr. Joseph, our senior author and interventional pulmonologist. Using the previous CT scan, the ion system generated a virtual bronchoscopic image and marked a target in the posterior superior segment of the right lower lobe. We reached this target, aspirated approximately 150 ml of bloody purulent material, and we lavaged the abscess with normal saline until the effluent was clear. We sent this fluid and bronchial brushings for pathologic investigations. We discharged the patient on the very same day with 14 days of Augmentin. Later on, the microscopy and cultures of the fluids that we sent showed numerous WBCs, but no bacteria, fungal elements, or acid-fast bacilli. The patient returned three weeks later to our center and had significant clinical improvement. As you can see here, the chest x-ray at follow-up showed almost complete resolution of the lung abscess. So as you're all aware, lung abscesses are severe necrotizing infections that typically require prolonged IV antibiotics for treatment. Traditionally, the options for abscesses not responding to antibiotics involved surgery, which was preferred for more centrally located abscesses, or transthoracic percutaneous drainage, which was preferred for peripheral abscesses. However, both these modalities were associated with significant complications, a high morbidity, and longer hospital stays. So in view of these risks, and we had a senior interventional pulmonologist, we opted to use the ION endoluminal system instead. So now the use of the ION system has been very well described for the diagnosis of peripheral pulmonary nodules, that is in malignancy lung cancer screening. The ION system allows greater distal access, and it also has greater navigational accuracy. The bend angle of the catheter allows us to navigate tortuous bends, and shape sensing corrects any tip deflection. However, to our knowledge at least, the use of the ION system for aspiration of a lung abscess refractory to oral antibiotics has not been reported. So to summarize, in our patient, the ION system allowed accurate localization, as well as drainage of an abscess in a traditionally inaccessible location. Following drainage of the abscess, we chose to prescribe empiric broad-spectrum antibiotics to clear any residual infection, despite the negative cultures. We assumed that these negative cultures were likely due to his prior oral antibiotic course. On follow-up, our patient had significant clinical and radiologic improvement, he had minimal complications of the procedure, and was discharged the same day. So in conclusion, the ION shape sensing robotic navigational bronchoscopy system permits the safe and accurate diagnosis and management of complex lung infections, including lung abscesses. Lung abscess drainage using this system, followed by oral antibiotics, can ensure early discharge and good outcomes, while being significantly less invasive than other traditional interventions. Thank you. ♪

Ion robotic guided navigational bronchoscopy system

antibiotic refractory lung abscess

42-year-old male

cavitary lung mass

robotic navigational bronchoscopy

abscess aspiration

saline lavage

less invasive alternative

improved patient outcomes