Call, J

Abstract Background Ventilated patients in the intensive care unit are often complex and require multiple care team members including bedside nurses, respiratory therapists, advanced practice providers, and physicians. A Quality Improvement initiative was created to address any barriers in communication. Spontaneous breathing trials (SBT) are often used as a surrogate for multidisciplinary communication. Both Respiratory therapist (RT) and provider led spontaneous breathing trial protocols are often performed but not necessarily documented or communicated appropriately. Our primary aim was to increase spontaneous breathing trial documentation from a baseline of 12% to 80% with a counterbalance of not increasing the 24-hour reintubation rate. Methods Using the DMAIC framework, we defined the gap in quality by getting baseline patient data for 3 months including SBT completion rate, SBT documentation rate, time to first SBT, total time on ventilator, 24-hour reintubation rate, and total ICU days. All care team members including providers, RTs, and nurses completed a 10-questions Likert 5-scale survey regarding their views of multidisciplinary communication and SBT completion. We identified the lack of documentation of SBTs and implemented a standardized respiratory therapy shift summary note which included SBT details and major ventilator changes. We then collected the same data over 3 months after implementation. Results Post intervention analysis revealed documentation of daily spontaneous breathing trials improved from 12% to 79%. Pre and post intervention means for patient focused outcomes were statistically unchanged for time to first SBT 26 hours vs 32 hours (p = 0.16), Total ventilator time 5.6 vs 5.4 (p = 0.83), total ICU days 1.9 days vs 2.7 days (p = 0.11), and reintubation rate 14% vs 15%.Survey results showed that there was a statistically significant improvement in overall satisfaction regarding multidisciplinary communication, satisfaction regarding ventilator management discussion on rounds, and if documentation amount was appropriate. Also, there was a significant improvement in the percentage of care team members that were aware of daily SBTs occurring. Conclusion The implementation of RT shift summary greatly improved staff member satisfaction, multidisciplinary discussion during rounds, and awareness of SBT occurrence among providers, RTs, and nurses. While patient centered outcomes were statistically unchanged over this very brief period of observation, having better staff satisfaction and communication may eventually lead to improved outcomes over time and can lead to further analysis to avoid mishaps that can arise from miscommunication. This abstract is funded by: None

Abstract Background Spinal cord ischemia (SCI) is an uncommon but devastating complication of Veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Peripheral femoral cannulation, while rapidly deployable, may compromise spinal cord perfusion. We report a case of thoracolumbar spinal cord ischemia presenting as paraplegia with cauda equina enhancement in a patient on femoral VA-ECMO. Case Presentation A 57-year-old man with nonischemic cardiomyopathy (EF 30%), atrial fibrillation on apixaban, and ICD (2023) suffered a witnessed out-of-hospital cardiac arrest requiring 45 minutes of CPR before return of spontaneous circulation. Peripheral femoral-femoral VA-ECMO was initiated, complicated by left femoral artery injury requiring repair. He was supported with the right axillary Impella 5.5 and listed UNOS Status 1 for heart transplantation. On ECMO day 5, the patient developed acute bilateral lower extremity weakness with preserved sensation and allodynia of the soles. Neurologic exam demonstrated flaccid paralysis below the quadriceps, consistent with a T12 motor level (ASIA C). Given his prolonged low-flow state and ECMO configuration, spinal cord ischemia was suspected. Hemodynamic augmentation and conversion of ECMO drainage from femoral to left subclavian were performed, along with corticosteroids. Following orthotopic heart transplantation on 8/8/2025, MRI of the thoracic and lumbar spine showed thickening, clumping, and enhancement of the cauda equina nerve roots without cord infarction. CSF analysis was negative for infection or inflammation, supporting an ischemic etiology. Despite rehabilitation and neuropathic pain management with pregabalin, lower extremity weakness persisted. He was discharged to inpatient rehabilitation with residual paraplegia. Discussion SCI is a rare neurological complication of femoral VA-ECMO, likely resulting from compromised spinal perfusion due to retrograde aortic flow, vascular injury, or systemic hypoperfusion during cardiac arrest. Post-ischemic cauda equina enhancement may reflect reperfusion-related breakdown of the blood-nerve barrier. Conclusion This case underscores the need for early recognition of spinal cord ischemia in ECMO-supported patients with new-onset paraplegia. Maintaining adequate mean arterial pressure, minimizing femoral arterial compromise, and early reevaluation of cannulation strategy may mitigate irreversible neurologic injury. This abstract is funded by: None

Abstract Primary Ciliary Dyskinesia (PCD) is a rare, genetically heterogenous disorder of motile cilia, leading to impaired mucociliary clearance and chronic respiratory disease. Its clinical presentation often overlaps with common conditions, including obstructive pulmonary diseases, contributing to diagnostic delays. Mutations in the DNAH11 gene are associated with PCD, but patients frequently lack the classic ultrastructural ciliary defects. We present a case which highlights the importance of considering rare ciliopathies in patients with refractory respiratory symptoms and the evolving role of genetic testing in diagnosis. A 44-year-old woman with early onset asthma was referred for evaluation of recurrent pneumonias, occurring biannually in recent years. She had been affected by respiratory disease since childhood. Despite aggressive asthma management, including long-term mepolizumab, she reported frequent pneumonias and persistent respiratory symptoms. Pulmonary function tests demonstrated obstructive physiology with bronchodilator responsiveness. Chest CT revealed diffuse cylindrical bronchiectasis, small airway disease, and a tree-in-bud pattern. Initial genetic testing identified heterozygous variants in DNAH11 and AP3D1. Whole genome sequencing later revealed a maternally inherited, likely pathogenic, DNAH11 variant and a paternally inherited variant of uncertain significance (VUS), suggesting a compound heterozygous state. Although not definitively diagnostic, this genetic profile, combined with lifelong respiratory symptoms, and imaging findings, raised strong clinical suspicion for PCD. She was treated targeting both asthma and PCD. Her regimen included a combination inhaler of fluticasone, umeclidinium, and vilanterol, as-needed albuterol, mepolizumab, and the addition of airway clearance focused techniques, including nebulized hypertonic saline, flutter valves, and chest physiotherapy. She demonstrated significant symptomatic improvement and a dramatic reduction in pneumonias or exacerbations. This case underscores the diagnostic complexity of chronic respiratory disease in young adults. PCD should be considered in patients with early-onset, persistent respiratory symptoms and recurrent infections, particularly when standard asthma therapies fail. DNAH11 mutations are known to cause PCD, often without detectable ciliary ultrastructural abnormalities, making diagnosis reliant on clinical features, nasal nitric oxide levels, high-speed video microscopy, and genetic testing. Compound heterozygosity involving a pathogenic variant and a VUS, as seen in this case, is not definitively diagnostic per current ATS/ERS guidelines, but may support a clinical diagnosis when aligned with phenotype and imaging findings. This case illustrates the importance of a multidisciplinary approach, including pulmonology, allergy, genetics, and immunology, in evaluating complex respiratory presentations. Early recognition and tailored therapy, including airway clearance and infection prevention, are critical to improving patient outcomes and quality of life in patients with suspected PCD. This abstract is funded by: None