Citations

Abstract Introduction Custom stents are a fast-evolving and revolutionary therapy for use in patients who require therapeutic stenting options due to a variety of tracheal, bronchial, and parenchymal diseases. The combination of increasing high-resolution CT imaging with 3-D printing technology has allowed for even greater flexibility in therapeutic treatment. Returned mesh is a well-described phenomenon in the medical literature and can create a wide variety of difficult to manage complications. Description The patient is a 64-year-old male with a past medical history of tracheobronchomalacia status post tracheoplasty with prolene mesh placement in April 2011 which was complicated by erosion of mesh through the membranous airway in April 2017. He subsequently underwent a right thoracotomy with a muscle flap reconstruction of the membranous trachea in May 2017. This was then complicated by a diverticulum of the distal trachea that was non-communicative with the esophagus and chronic stenosis of the left mainstem bronchus with residual mesh retained in the posterior membranous left mainstem bronchus. He had a custom Y-stent placed for the first time in February 2022 due to persistent sensation of shortness of breath along with productive cough. He experienced immediate relief after placement of his custom stent and has since demonstrated remarkable stability, rarely requiring unscheduled bronchoscopy for mucous clearance. He has nonetheless derived immense benefit from stenting from a symptomatic standpoint since initial placement in 2022. Discussion Customized stents utilizing 3-D printing technology have allowed far more flexibility to the clinical approach of patients with complex airway pathology. As tracheal and bronchial reconstruction surgeries continue to involve more complicated management modalities, including the use of mesh, complications will continue to arise. Mesh erosion is a potentially devastating complication from tracheobronchoplasty. It will, therefore, be important to facilitate treatment of complications from these and other modalities. Therapeutic bronchoscopy with custom stent placement will almost certainly continue to evolve as an effective tool in the management of patients such as these. This abstract is funded by: None

Abstract Introduction Nuclear protein in testis (NUT) carcinoma, formerly known as NUT midline carcinoma, is a rare and highly aggressive subtype of squamous cell carcinoma characterized by NUTM1 gene rearrangements. It typically affects children and young adults and shows a predilection for midline structures of the head, neck, and thorax. We describe a rare case of NUT carcinoma in an elderly patient presenting with central airway obstruction treated with tumor debulking, devascularization, and pulsed electric field (PEF) ablation. Case An 89-year-old woman on chronic anticoagulation for atrial fibrillation presented with respiratory distress and hemoptysis requiring intubation and mechanical ventilation. Chest CT revealed a developing right lower lobe infiltrate and bronchoscopy demonstrated a non-obstructing right lower lobe endobronchial lesion. Pathology of the lesion confirmed NUT carcinoma but the patient was lost to follow-up. Two months later, she presented with altered mental status and respiratory failure. Imaging revealed a 4.6 x 2.6 cm mass at the level of the cricoid cartilage causing approximately 75% tracheal obstruction with tracheal wall invasion. She underwent rigid bronchoscopy with tumor debulking and devascularization, achieving >80% tracheal patency post-procedure. EBUS-guided PEF ablation was then performed to target residual bulky tumor found in the paratracheal area. Given her age, comorbidities, and poor performance status, palliative chemotherapy was deferred and palliative radiotherapy was offered to limit tumor progression. Discussion NUT carcinoma is a rare and aggressive malignancy with a poor prognosis. This case demonstrates rapid tumor progression leading to respiratory failure within two months of initial diagnosis. Management options for malignant central airway obstruction in non-surgical candidates may include endobronchial debulking and ablative therapies. In this case, EBUS-guided PEF ablation, a non-thermal technique that delivers brief electric pulses to induce tumor apoptosis while sparing adjacent structures, was successfully used to treat residual disease with the goal of reducing marginal regrowth and maintain airway patency. PEF ablation has been described in percutaneous and bronchoscopic management of early stage non-small cell lung cancer; however, its application in central airway obstruction represents an innovative therapeutic approach. Although chemoradiation may be considered when feasible, no standard regimen exists for NUT carcinoma. It typically responds poorly to conventional therapies, underscoring the importance of complementary local treatment strategies in select patients. This case highlights the rapidly progressive course of NUT carcinoma and demonstrates the potential role of PEF ablation as a novel adjunct in the palliative management of malignant central airway obstruction. This abstract is funded by: None

Background: Pneumocystis jirovecii pneumonia (PJP) is life-threatening for immunocompromised patients. No consensus exists on PJP prophylaxis for immunosuppressed patients without HIV, transplant, or cancer. Methods: We retrospectively reviewed the electronic health records of adult immunosuppressed patients with PJP diagnosed between 1990 and 2020 at Mayo Clinic. Patients with HIV, solid organ transplants, or cancer were excluded. Demographic data, treatments, and outcomes were manually abstracted. Results: The most common indications for immunosuppression were rheumatoid arthritis (19.7%), vasculitis (18.1%), and interstitial lung disease (ILD) not related to connective tissue disease (17.6%). Despite having high risk of PJP, 86.0% of patients did not receive PJP prophylaxis. Corticosteroids were the most common immunosuppressive agent used (84.5%), with 64.4% of patients receiving high-dose treatment. Nonbiologic disease-modifying antirheumatic drugs were used for 49.7%, including methotrexate (51.0%), azathioprine (22.9%), and hydroxychloroquine (11.5%). Biologics were prescribed for 25.4%, primarily rituximab (59.2%) and infliximab (22.4%). Hospitalization occurred for 76.7% of patients; 70.3% required intensive care unit (ICU) admission, and 46.6% received mechanical ventilation. The in-hospital mortality rate was 30.4% overall and 53.6% for patients on ventilation. Predictors of death included ILD [odds ratio (OR), 4.61; 95% CI, 1.75-13.00], ICU admission (OR, 3.60; 95% CI, 1.19-11.08), and ventilator use (OR, 3.46; 95% CI, 1.30-9.79). Biologic use was associated with lower odds of death (OR, 0.34; 95% CI, 0.11-0.89). Conclusions: Most patients in our cohort did not receive PJP prophylaxis, and outcomes were poor with high mortality rates. Standardized risk stratification and prophylaxis protocols are needed to improve outcomes.

Abstract Introduction: Prolonged mechanical ventilation can often be complicated with post-intubation tracheal stenosis (PITS). It usually manifests within few weeks following extubation. However, delayed presentations are rare and have disastrous outcomes if not identified. Early recognition of stridor and dyspnea post-extubation is crucial for timely intervention. We report a case of late presentation of PITS in a 67-year-old female patient with new-onset stridor after prolonged intubation. Case: A 67-year-old female with past medical history of coronary artery disease, type 1 diabetes, obstructive sleep apnea presented with a six-week history of progressive dyspnea on exertion and stridor. This occurred in the context of a three-week intubation following a pulseless electrical activity (PEA) arrest over five months prior. Immediately post-extubation, the patient had developed stridor without hypoxia or exertional symptoms and was subsequently discharged home without further investigation. On this presentation, she was afebrile and saturating 95% on room air with audible inspiratory stridor at bedside. Respiratory viral panel and autoimmune work up was negative. Computed tomography (CT) scan noted a significant circumferential narrowing in the proximal portion of the trachea measuring 2.5 cm in length with 0.5 cm in width with associated wall thickening. She was managed with 2.25% racemic epinephrine as needed and prednisone 10 mg daily with rescue continuous positive airway pressure (CPAP) until intervention could be safely performed after clopidogrel washout. On Day 5, she underwent rigid bronchoscopy with extensive CO2 laser vaporization (Fig. B) of scar release and paclitaxel-coated balloon dilation of the 3 mm narrowing (Fig. A) to 12 mm (Fig. C). Her stridor resolved with significant improvement in dyspnea and exercise tolerance. She was subsequently discharged on a steroid taper with outpatient interventional pulmonology follow up for repeat rigid bronchoscopy in 4 weeks to evaluate for restenosis. Discussion: Tracheostomy is often considered when extended period of intubation is anticipated as it can lead to increased risk of complications like PITS. It is important to have a high index of suspicion for tracheal stenosis in patients with a history of prolonged mechanical ventilation presenting with new-onset stridor, even when the symptoms are mild or intermittent. Early recognition and timely intervention can prevent the progression of stenosis and improve morbidity and clinical outcomes. Additionally, these patients tend to have an increased incidence of recurrence which requires close follow up for restenosis.

Abstract Rational: Talc pleurodesis is an effective intervention for preventing recurrent pleural effusions and pneumothoraces, particularly in non-surgical candidates. Due to its efficacy and safety, it is recommended as the most effective sclerosant for pleurodesis. However, in some cases, the initial pleurodesis fails, necessitating a repeat procedure. The efficacy of repeat talc pleurodesis after an initial failure is an area that requires further exploration. This study explores the safety and efficacy of repeat talc pleurodesis among patients who did not respond to the initial intervention. Methods: This retrospective study analyzed hospitalized patients who underwent 4g talc slurry pleurodesis from 2019 to 2024, focusing on demographics, comorbidities, initial pleurodesis failure, and recurrence rates. Pleurodesis failure was identified by lung sliding, recurrent effusion, or pneumothorax during the same hospitalization. The primary outcome was recurrence post-discharge, assessed by pleural effusion or pneumothorax within 180 days post-repeat pleurodesis. Results: This study included 94 patients (52.1% male, 47.9% female) with a mean age of 67.6. Among them, 79 (84%) received a single 4g dose of talc, while 15 (16%) received multiple 4g talc doses for initial pleurodesis. Recurrence occurred in 20 (25.3%) of the single-dose group and 1 (6.7%) of the multiple-dose group within 180 days, though the difference was not statistically significant (p=0.112). Recurrence-free rates were 93.6% at 30 days, 85.1% at 90 days, and 77.7% at 180 days. Of the 20 patients with recurrence after a single 4g dose of talc, 8 (40%) underwent repeat pleurodesis, with only one recurrence requiring surgical intervention. Additionally, there was no recurrence after repeat talc pleurodesis in the one patient with recurrence after receiving multiple 4g talc doses for initial pleurodesis. No associations were found between recurrence rates and factors like gender (p=0.213) or comorbidities (emphysema, COPD, lung malignancy). Chest pain was a common complaint, but no cases of respiratory distress were reported post-pleurodesis. Conclusion: The efficacy of initial talc pleurodesis (77.7%-93.6%) in this cohort aligns with existing literature. Multiple-dose talc pleurodesis effectively prevented recurrence in 93.3% of patients, with no reported respiratory distress. Additionally, repeat talc pleurodesis was successful in 87.5% of those with recurrence after an initial single 4g dose. These findings support multiple-dose talc pleurodesis and repeat talc pleurodesis as safe and effective options for preventing recurrence post-initial failure and post-repeat talc pleurodesis, respectively. Although no significant recurrence predictors were identified, future research could focus on patient-specific factors to enhance treatment selection and optimize outcomes.

Abstract Rationale: Airway-stenosing disease is a significant clinical problem in multiple populations. While the immediate endoscopic and clinical response to bronchoscopic interventions are high, rates of clinically significant recurrence are elevated, and often require multiple and frequent reinterventions. Newer strategies to prevent recurrence of central and proximal airway stenosis are needed. Methods: Retrospective review of bronchoscopic balloon bronchoplasties performed at the Mayo Clinic utilizing paclitaxel coated balloons (PCB) in 2023-2024 for recurrent airway stenosis. IN.PACT Admiral and AV balloons (sizes 5-12 mm, 3.5 mcg/mm2 paclitaxel dose) were used with an inflation time of 2-3 minutes. Procedural success was defined as <50% airway stenosis or resolution of the procedural indication. Reintervention was considered only if a therapeutic bronchoscopy was subsequently required to address the same lesion treated with PCB. Only patients with follow-ups >90 days were included in the reintervention inter-procedural time analysis. Results: Thirty-three procedures were performed in 18 patients. Seventeen (51%) for lung transplantation-associated stenosis (29% anastomotic/perianastomotic, 76% lobar and segmental stenoses), 8 (24%) for granulomatous polyangiitis-associated stenosis, 3 for postintubation tracheal stenosis and 2 for chemical/pill injury. Eighteen cases (54%) utilized an additional dilation modality (12 non-coated balloon dilation, 4 rigid dilation), 5 spray cryotherapy, 6 other ablative therapies (4 CO2-laser, 2 electrocautery cuts), and 6 received an airway stent during the same procedure. 57% percent of interventions occurred in the lobar, 27% mainstem/bronchus intermedius, 9% tracheal, 7% segmental airways. Thirty-one (93%) cases had a satisfactory initial endoscopic result. The median number of bronchoscopic therapeutic interventions required before the use pf PCB was 5 (IQR 2.5-11.5), which significantly decreased to 0.1 (IQR 0-1, range 0-9) after PCB (p <0.001). The reintervention-free survival significantly increased after PCB dilation from a median 35 days (IQR 28.7-80.5) to 132 days (IQR 64-197; p=0.004). Twenty-one cases required subsequent bronchoscopies, sixteen (76%) of which demonstrated improvement in lesion severity when compared to the results of prior interventions. Only 16 (48%) required therapeutically addressing the same lesion. Only 2 minor complications occurred (6%, self-limited bleeding and unplanned admission), none related to paclitaxel use. Six-month mortality was 3% from an unrelated cause. Conclusions: The locoregional antiproliferative effects of paclitaxel show promise in preventing recurrence, minimizing the need for repeat procedures, and extending intervals between interventions in patients with recurrent, predominantly benign airway stenosis. Its use is feasible, safe, and future research is warranted, particularly comparing PCB with the currently available strategies.

Background: CO2 Laser (CO2L) technology deployable through flexible endoscopes now allows for their use throughout the airway, although published data are limited. Methods: Retrospective analysis of CO2L bronchoscopic procedures, excluding glottic and subglottic interventions. Procedural success was defined as >50% visual reduction in airway obstruction in the area treated or resolution of the procedural indication. Results: Seventy-two procedures were performed on 36 patients. Nonmalignant indications comprised 66%: stent-associated granulation tissue (28%), granulomatosis with polyangiitis lesions (23%), and lung transplant-related granulation tissue (16%) were the most common. Bronchoscopic access was flexible only in 81% and primarily rigid (combined with flexible) in 18%. The site of intervention was the trachea at 19%, the mainstem at 56%, and lobar/segmental airways at 45%. Procedural success was 89%. CO2L was used exclusively in 19%; in 81%, additional techniques were required, most commonly balloon dilation (59%), cryo-debulking (23%), and rigid dilation (16%). Malignant indications had a nonsignificant trend toward requiring adjuvant techniques (P=0.05). Seventy-six percent of the patients required more than 1 procedure. CO2L exclusive cases had no statistically different needs for subsequent therapeutic bronchoscopies (P=0.10) or time to reintervention (109 vs. 41 days, P=0.07), and reintervention-free survival was similar (P=0.10) and difficult to predict. The complication rate attributable to CO2L was 2.7%. Conclusion: CO2L is a safe and useful tool when precise cutting and vaporization are desired. Its use in multi-modality approaches has high levels of success in adequately selected lesions, adding an ablative potential to dilation techniques. Vasculitis-associated scars/webs and granulation tissue (including stent-associated) appear to be ideal targets.