Citations

Abstract Purpose Diagnostic bronchoscopy plays a critical role in management for immunocompromised patients hospitalized with new pulmonary infiltrations. Most existing data on bronchoscopy in immunocompromised patients are derived from ICU cohorts or mixed inpatient/outpatient populations. This study aimed to assess the relationship between specific immunosuppression types-classified per the 2025 IDSA guidelines-and bronchoscopy yield and its impact on hospital management among non-ICU patients with new pulmonary infiltrates compared to non-immunocompromised. Methods A retrospective review of 447 hospitalized (immunocompromised and non-immunocompromised) patients who underwent bronchoscopy for new pulmonary infiltrates was completed between January 2022 and December 2024 in a single center tertiary care center. Data collected included demographics, immunosuppression type, and bronchoscopy results (cell count, differential, cultures, biopsies). Post-bronchoscopy management changes were also recorded. Multivariate logistic regression was used to correlate immunosuppression subtypes to diagnostic yield and management impact. Results The overall positivity rate for significant findings was 46% (n = 205). 367 of 447 (82%) met criteria for immunosuppressed. The immunosuppressed positivity rate was 46% vs 45% for non-immunosuppressed (P=.43). Broken down by subtype, positivity rates were: Active immunotherapy 33%, active chemotherapy 45%, hematologic malignancy 45%, hematopoietic stem cell transplant 44%, solid organ transplant 43%, active HIV 66%, primary immunodeficiency 78%, autoimmune modulator therapy 45%, daily prednisone use >20 mg 45%. Only primary immunodeficiency was associated with a statistical higher likelihood of a positive bronchoscopy (Odds ratio 4.69; P = 0.025).The overall rate of a significant change in management as a direct result of the bronchoscopy was 26%. Immunosuppressed was 26% compared to 22% for non-immunosuppressed (p = 0.5). Broken down by subtype management change rates were: Active immunotherapy 66%, active chemotherapy 18%, hematologic malignancy 19%, hematopoietic stem cell transplant 26%, solid organ transplant 32%, active HIV 100%, primary immunodeficiency 78%, autoimmune modulator therapy 70%, and daily prednisone use >20 mg 23%. Active immunotherapy and active immunomodulator therapy were correlated with a significant change in management (OR 8.9; P = 0.02, OR 3.6; P = 0.02, respectively). Conclusions Bronchoscopy yield and management impact were similar between immunosuppressed and non-immunosuppressed hospitalized patients. However, bronchoscopy more frequently influenced management in patients receiving active immunotherapy or immunomodulators, supporting earlier diagnostic use in these populations. This abstract is funded by: None

Abstract Introduction Chronic granulomatous disease (CGD) is an inherited immunodeficiency caused by NADPH oxidase defects, leading to impaired reactive oxygen species (ROS) production and defective intracellular pathogen killing. Typically diagnosed in childhood, CGD manifests as recurrent infections by catalase-positive bacteria and fungi. Immune dysregulation with hyperinflammatory responses may occur even without infection. We present a case of severe immune dysregulation in CGD with concomitant pulmonary nocardiosis. Case Summary A 37-year-old man presented with one month of progressive productive cough, fevers, malaise, vomiting, poor oral intake and high ileostomy output. He was diagnosed with X-linked CGD at age 5 which was complicated by recurrent skin infections and fulminant colitis requiring subtotal colectomy. Laboratory studies showed elevated WBC and CRP of 282.77mg/l. CT scan of chest showed widespread pulmonary nodules and dense consolidation in the left upper lobe with heterogeneous diminished enhancement suggesting necrosis (Fig 1). Cell-free pathogen DNA sequencing testing on sputum identified Nocardia cyriacigeorgica DNA. Fungal cultures on bronchoalveolar lavage grew Nocardia cyriacigeorgica. He was treated with imipinem-cilastin, sulfamethoxazole-trimethoprim, and posaconazole. His course was complicated by refractory fevers (T.max 40.5 C), septic shock, and ARDS. He had two episodes of extubation failure characterized by sudden recrudescence of fever, hemodynamic change, and worsening oxygenation. Each of these episodes occurred during steroid tapers and improved after reinitiating full stress doses. Immune dysregulation was suspected, and he was maintained on 0.8mg/kg/day of methylprednisone with plans for a prolonged taper. He gradually improved, was weaned off oxygen, and discharged home. Discussion Pulmonary nocardiosis is common in CGD, particularly without prophylaxis. Case series report that some patients fail to improve with antimicrobials alone and require adjunctive corticosteroids to control excessive inflammation, as seen in this patient. Immune dysregulation in CGD involves both defective microbial killing and excessive inflammation. Absent ROS results in persistent NF-κB and inflammasome activation, driving production of pro-inflammatory cytokines, leading to granuloma formation, autoimmunity, and IBD-like colitis. Granulomatous inflammation may cause gastrointestinal or genitourinary obstruction, and up to half of patients develop colitis. Exaggerated inflammatory responses to infection or environmental triggers can also mimic hemophagocytic lymphohistiocytosis (HLH). Concurrent susceptibility to infections and inflammation complicates diagnosis and management. Corticosteroids remain first-line for inflammatory episodes and may be combined with antibiotics, as in disseminated nocardiosis, to control hyperinflammation. However, long-term use is limited by adverse effects, and steroid-sparing agents lack proven efficacy in CGD. Hematopoietic stem cell transplantation remains the only curative option in CGD. This abstract is funded by: None

Abstract Rationale Clear and accurate communication is essential in critical care, yet patients with non-English language preferences (NELP) often face limited access to professional interpreters. Although machine translation has been explored in healthcare, most studies have focused on written translation. Their use in real-time, two-way interpretation specifically for high-stakes ICU conversations remains largely unexamined. To bridge this gap, we developed AI-TransLATE (AI-enhanced Transition to Language-Agnostic Transcultural Engagement), a voice-to-voice multilingual interpretation tool designed to support real-time interactions in critical care. Following successful initial validation, we evaluated clinicians’ perceptions of its usability in simulated ICU encounters and compared its performance with commercially available AI tools, including Gemini and ChatGPT. Methods We developed three standardized ICU role-play scenarios focused on shared decision-making regarding ECMO, tracheostomy, and comfort care, designed to encourage natural, unscripted dialogue. Clinicians were asked to use the AI translation tools during these encounters in Spanish, Chinese, or Arabic, while a bilingual research team member acted as the patient’s family member. After each simulation, participants completed a post-session survey evaluating communication quality, satisfaction (using a 5-point Likert scale), and usability through the System Usability Scale (SUS). Results Eighteen clinicians participated, including residents, fellows, and attending physicians with an average of 3.6 ± 1.2 years of postgraduate experience. Fifty-four post-simulation surveys were completed across Arabic, Chinese, and Spanish languages comparing AI-TransLATE, ChatGPT, and Google Gemini. Participants rated the simulation as realistic across all cases (ECMO = 3.94 ± 0.66; Tracheostomy = 4.22 ± 0.43; Comfort Care = 4.06 ± 0.42; p = 0.32). Satisfaction was highest for AI-TransLATE (4.11 ± 0.68) and ChatGPT (4.00 ± 0.69) but lowest for Gemini (2.06 ± 1.00; p < 0.001). Willingness to use in real life followed the same trend. (AI-TransLATE = 4.00 ± 0.69, ChatGPT = 3.89 ± 0.96, Gemini = 2.00 ± 1.03 (p < 0.001)). SUS scores supported these findings (AI-TransLATE = 71.25 ± 13.35; ChatGPT = 72.22 ± 15.57; Gemini = 40.28 ± 21.30; p < 0.001), corresponding to good usability for AI-TransLATE and ChatGPT and poor usability for Gemini. Clinicians mentioned interruptions, uneven translation flow, and difficulty judging accuracy, but appreciated it when the AI-TransLATE conveyed tone and intonation, enabling smoother, more natural communication. Conclusion Overall, AI-TransLATE and ChatGPT demonstrated strong usability and satisfaction, showing promise as clinical communication tools; however, further validation in real-world ICU settings is warranted, and data privacy and confidentiality remain important considerations. This abstract is funded by: Critical care research committee mayo clinic

Abstract Introduction Large Language Models (LLMs) have proven effective at analyzing unstructured and structured data from electronic health records (EHR). Their reliance on static EHR data means they miss the dynamic, high-resolution physiological signals that are the first indicators of patient decline, creating a fundamental data lag as clinical documentation of an event may occur hours after its onset. This represents a critical gap in the ability to develop truly effective triage tools. Furthermore, while LLMs can synthesize multi-source data for acuity assessment, they exhibit known limitations, including hallucinations that constrain autonomous use in safety-critical settings. In contrast, a Vision-Language Model (VLM) with strong image-grounded clinical reasoning can interpret vital sign trend images, surpassing the limitations of current EHR-based models. This approach provides immediate triage evaluations that lead to earlier detection of patient deterioration. Methods This mixed-methods study deployed a VLM (Gemini 2.5) integrated within the eICU dashboard. We used near-real-time two-hour trends in heart rate, blood pressure, respiratory rate, and oxygen saturation from consecutive patient cases during alerts in hospital floor units monitored by eICU that admit acute medical and surgical patients. To increase the diversity of the sample, we sought routine cases from patients without alerts and emergent cases from patients admitted to the medical, surgical, trauma, and mixed ICUs. A structured context prompt was used to generate a standardized summary including clinical interpretation, data quality and artifact assessment, triage recommendation, and the model’s chain-of-thought reasoning. Results We included patients from Mayo Clinic Rochester, MN, using an 800-patient cohort for prompt development and a 100-patient cohort for validation against clinically adjudicated results. In the validation cohort the VLM achieved 80% accuracy (80/100). An analysis of the 20 incorrect predictions revealed a clear pattern of conservative over-triage: 80% (16/20) of errors were clinically acceptable adjacent-class discrepancies (routine↔urgent or urgent↔emergent). Only 4/20 discrepancies represented a substantive misclassification. Most errors therefore reflected conservative prioritization rather than incorrect assessment. The model demonstrated a perfect safety profile, underestimating patient acuity in 0% of cases, and thus avoiding the most clinically dangerous error. These results confirm the feasibility of VLM-based approach and provide a strong foundation for the proposed work. Conclusion This VLM performs cross-modal reasoning by fusing deep visual perception with broad clinical context. The result is a fully contextualized and explainable triage prioritization, which provides direct decision support and integrates into the clinical workflow, allowing for faster and more confident acute care assessments. This abstract is funded by: none

Abstract Rationale Critical care education has been identified as a global priority to improve the early identification and management of common syndromes, including sepsis and respiratory failure. International practice varies widely, and frontline clinical team perspectives remain poorly defined. The CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) program provides a structured, checklist-based approach shown to improve the delivery of best practices and patient-centered outcomes worldwide. Over the past decade we have performed a needs assessment at the start of each international CERTAIN program. We performed a retrospective analysis of these data to examine the critical care domains prioritized by frontline interprofessional teams to inform global training priorities. MethodsWe developed an anonymous online survey consisting of 20 previously defined activities essential to the practice of critical care. Participants ranked these activities using Q-sort methodology on a forced distribution scale from -4 (lowest priority) to + 4 (highest priority). Individual rankings were summed across all participants to generate aggregate scores for each activity, with higher values reflecting greater collective prioritization. Aggregate scores were calculated for the entire cohort and each site and summarized with bar plots to illustrate prioritization patterns across critical care domains. ResultsA total of 213 intensivists, emergency medicine physicians, nurses, and pharmacists from hospitals in China (75), Cambodia (70), Croatia (31), Japan (24) and India (13) completed the survey. The distribution of priorities across content domains is illustrated in Figure. Management of shock, sepsis, mechanical ventilation, and respiratory failure received the highest aggregate scores. Interprofessional critical care coordination was the only process of care activity identified as high priority, and transitions of care, patient centered communication, and shared decision making were consistently ranked lowest. While minor variation existed across individual sites, resuscitation and the acute management of high-risk clinical conditions were consistently prioritized over processes of care and patient-centered care domains. ConclusionThis multicenter analysis demonstrates consistent interprofessional clinician prioritization of acute clinical management topics for training. These insights inform both areas of emphasis and highlight challenges that CERTAIN and other programs face to improve global patient care delivery. Variation in care processes has been consistently identified as the largest modifiable factor to improve patient outcomes, and cultural differences may present barriers to engagement on the best approaches to patient centered care. Figure. Distribution of aggregate Q-sort scores across 20 critical care activities. Scores represent summed participant rankings (n=213) from -4 (lowest priority) to +4 (highest priority). This abstract is funded by: None

Abstract Introduction Hepatopulmonary syndrome (HPS) is a rare condition where liver disease causes intrapulmonary vascular dilation, subsequently leading to intrapulmonary shunting and thus hypoxemia. Although diagnosis can be challenging, classical HPS features include dyspnea, platypnea, and orthodeoxia, which aid diagnosis. Timely diagnosis of HPS is crucial to provide adequate treatment, which ultimately involves supportive care while awaiting liver transplantation. This is a case of a patient who has a known history of alcoholic cirrhosis who presented to the pulmonology clinic with the chief complaint of progressive dyspnea. Investigations established the diagnosis of HPS, and the patient was referred for liver transplantation. Case A 65-year-old female with a past medical history of significant alcohol use, alcoholic cirrhosis, portal hypertension, recurrent upper gastrointestinal bleeding and a 40-pack-year history. She presented to the pulmonology clinic due to progressive dyspnea on exertion, which she had been experiencing for three years. Furthermore, home pulse oximetry readings were in the 80s, and she denied any cough, orthopnea, or peripheral edema. The patient had a previous echocardiogram with a bubble study, which identified concern for left-to-right shunting. Initially, it was perceived to be intracardiac; however, right heart catheterization was completed, and there was no evidence of an intracardiac shunt. Additionally, pulmonary pressures were normal, favouring intrapulmonary shunting. Physical examination was significant for orthodeoxia with oxygen saturation of 89 percent while upright, and 97 percent while supine, and the patient reported feeling less breathless when lying down. Pulmonary function testing was significant for a substantial reduction in diffusion capacity. Given the constellation of symptoms, including platypnea, orthodeoxia, and evidence of intrapulmonary shunting, with a background history of alcoholic cirrhosis, the patient was diagnosed with HPS and was referred for a liver transplant evaluation. Discussion This case identifies the importance of evaluation for HPS in patients with underlying liver disease and persistent shortness of breath. The constellation of liver disease, hypoxemia, and concern for intrapulmonary vascular dilation were telling for this patient. Currently, there is no medical intervention to cure HPS, and treatment revolves around supportive care and supplemental oxygenation while awaiting liver transplantation. After liver transplantation, patients will often experience improved oxygenation due to the correction of the intrapulmonary vasodilation, which in turn corrects the ventilation-perfusion mismatch. Although early postoperative mortality is slightly higher, long-term survival for HPS patients post-transplant is like that of non—HPS transplant recipients. Therefore, early diagnosis and referral for transplant evaluation are critical to optimize patient outcomes. This abstract is funded by: NONE

Abstract Background Sulfhemoglobinemia is a rare but potentially life-threatening dyshemoglobinemia resulting from the irreversible incorporation of sulfur into the heme moiety, producing hemoglobin species incapable of oxygen transport. Its clinical presentation often mimics methemoglobinemia, with cyanosis and oxygen saturation (SpO2) readings discordant from arterial partial pressure of oxygen (PaO2). Phenazopyridine, an over-the-counter urinary analgesic, has been implicated as a rare cause, in 3 previously documented cases. Prompt recognition is essential to avoid inappropriate therapy, particularly methylene blue, which can precipitate hemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Case Presentation A 71-year-old man with Parkinson’s disease, Crohn’s disease, and chronic anemia presented with unexplained cyanosis and SpO2 readings in the 70-80% range, despite a normal PaO2 of 180 mmHg and absence of respiratory symptoms. He had self-initiated phenazopyridine for dysuria three days prior. CT angiography of the chest and echocardiography with bubble study were unremarkable. Attempts to quantify methemoglobin and carboxyhemoglobin were unsuccessful due to analyzer errors. Laboratory evaluation revealed acute anemia (hemoglobin 5.7 g/dL), indirect hyperbilirubinemia, and low haptoglobin consistent with hemolysis. He was managed supportively with high-flow oxygen, and transfusion of two packed red blood cell units. Although initial G6PD levels were normal, testing during hemolysis can yield false negatives. Given this and the risk of methylene blue-induced oxidative stress, conservative management with ascorbic acid was chosen. The patient’s SpO2 improved gradually, and he was discharged on hospital day three. Send-out tests later confirmed sulfhemoglobinemia (1.1%), elevated cytochrome b5 reductase activity, and normal methemoglobin. Discussion This case underscores the diagnostic and therapeutic challenge of differentiating sulfhemoglobinemia from methemoglobinemia. Both disorders produce functional hypoxia with SpO2-PaO2 dissociation, but sulfhemoglobin cannot revert to hemoglobin and requires erythrocyte turnover for resolution. While methylene blue is the standard therapy for methemoglobinemia, it is ineffective for sulfhemoglobinemia and contraindicated in G6PD deficiency. In our patient, supportive care and transfusion facilitated recovery. Using the Naranjo Adverse Drug Reaction Probability Scale, the causality score was 7, indicating a highly probable relationship between phenazopyridine exposure and sulfhemoglobinemia. A high index of suspicion for G6PD deficiency as well as dyshemoglobinemia with a multidisciplinary collaboration are essential for diagnosis and management of unexplained cyanosis. This abstract is funded by: None

Abstract Introduction Phrenic neuropathies (PN) are an important cause of dyspnea and hypercapnic respiratory failure. A crucial yet often overlooked symptom is dyspnea associated with water immersion activities. This symptom which is frequently documented in patients with PN, carries a serious risk of drowning and should serve as a key clinical clue for underlying diaphragmatic weakness. This report details a case of severe unilateral diaphragmatic paralysis, where immersion dyspnea served as the respiratory harbinger guiding the diagnosis in a competitive athlete. Case Description A 47-year-old male athlete training for an Ironman triathlon, presented with exercise-induced dyspnea, wheezing and orthopnea following a major bike accident involving left sided trauma (rib fractures, pneumothorax, left clavicle/scapula fracture). Notably he reported difficulty swimming or water immersion dyspnea even before the accident. Chest x-ray revealed an elevated right hemidiaphragm. Pulmonary Function Tests (PFTs) showed normal baseline spirometry and diffusing capacity but Maximal Inspiratory Pressure (MIP) was reduced (51 cmH2O), indicating neuromuscular weakness. Cardiopulmonary Exercise Testing (CPET) demonstrated supranormal exercise capacity (Peak VO2 4.13 L/min, 122% predicted, Peak Work Rate 385 W, 170% predicted) with reduced breathing reserve of 2.4%, arguably normal with the other supranormal exercise parameters in a highly conditioned athlete. Electromyography (EMG) and nerve conduction studies revealed an absent right phrenic motor response while diaphragmatic ultrasound confirmed severe right hemidiaphragm atrophy (thickness 0.05 cm; normal >0.15 cm) and a poor thickening ratio (0.5; normal >1.2). Discussion Immersion dyspnea should immediately raise suspicion for phrenic neuropathy (PN) even in otherwise healthy and athletic individuals. In a Mayo Clinic study of 535 PN patients, only 4% (22 of 535) reported dyspnea triggered specifically by water immersion underscoring the rarity of this symptom. For 36% (8 of 22) immersion dyspnea was the first respiratory symptom and in 4.5% (1 of 22) it was the only symptom. Notably 18% (4 of 22) experienced near-drowning incidents. The hydrostatic pressure exerted by water worsens the mechanical disadvantage caused by a paralyzed diaphragm making immersion dyspnea a vital diagnostic warning sign. Because of its rarity but serious risks patients with diaphragmatic paralysis should be advised to avoid immersion activities particularly diving. This abstract is funded by: nnone

Abstract Rationale Treatment of hematologic malignancies has been revolutionized by Chimeric antigen receptor T -cell (CAR-T) therapy. Pulmonary complications are increasingly being reported, however, there are no standardized timelines for pulmonary function test (PFTs) assessment before or after the infusion. We aimed to evaluate changes in lung function (TLC, RV, FEV1, and FEV1/FVC) pre- and post-CAR-T therapy and examine whether these parameters correlate with the development of specific pulmonary complications. Methods We conducted a retrospective chart review of patients above the age of 18 with any malignancy who received CAR-T therapy between June 12, 2018, and December 26, 2023. Pre-CAR-T PFTs were obtained closest to the infusion date, and post-CAR-T PFTs were recorded at the earliest available time following infusion. Pre- and post-CART pulmonary function tests were compared using non-parametric paired tests. In addition, we examined the relationship between baseline PFTs and the subsequent occurrence of pulmonary complications after CAR-T infusion. The Wilcoxon signed-rank test was applied to assess both the magnitude and direction of change while Sign test was used to evaluate only the direction to confirm the consistency of results. These tests were chosen due to small sample size and non-normal distribution of data. Results Among the 68 patients in our cohort, paired pre- and post- CAR-T measurements of pulmonary function were available for 18 patients. FEV1 declined significantly post-infusion (2.70 ± 0.81 L vs 2.28 ± 0.74 L; Z= -2.55, p = 0.011), the FEV1/FVC ratio remained stable (77.8 ± 8.0 vs 80.9 ± 12.2, p = 0.53). Mean TLC and RV remained stable (TLC 5.70 ± 1.18 L vs 4.66 ± 1.02 L, p = 0.17 and 2.13 ± 0.62 L vs 2.00 ± 0.70 L, p = 0.58). There was no significant correlation between the baseline lung function and the development of pulmonary complications. Conclusion Only the pattern of FEV1 decline following CAR-T therapy infusion demonstrates a significant decline, whereas other PFTs, although reduced, did not show significance. While these findings may suggest a restrictive ventilatory pattern, additional data on lung volumes are required to accurately characterize the underlying type of pulmonary function impairment. Although limited by small sample size and non-uniform timing of PFT assessments, this highlights the need for a routine pre-CAR-T pulmonary function evaluation to inform patient selection and baseline risk stratification. This abstract is funded by: None

Abstract Background With recent advances in oncology, tyrosine kinase inhibitors like imatinib play a significant role in gastrointestinal stromal tumor (GIST) treatment but can cause rare pulmonary complications. When new respiratory symptoms arise after starting these agents, differentiating drug toxicity from other lung diseases is important for timely management. Case Presentation A 72-year-old man with GIST, recently started on imatinib, presented with acute dyspnea and hypoxia. His medical history included chronic obstructive pulmonary disease and a 40-pack-year smoking history. Chest CT revealed new bilateral interstitial infiltrates absent on imaging two months ago, prior to imatinib initiation. The differential diagnosis included imatinib-induced pneumonitis versus atypical infection. Bronchoscopy showed yellowish nodular mucosa throughout the trachea and bronchi, mucus plugging, and airway narrowing in the left lower lobe. Endobronchial biopsies demonstrated amyloid deposits consistent with tracheobronchial amyloidosis. The bronchoalveolar lavage was negative for infection and, therefore, corticosteroid therapy was initiated, resulting in clinical and radiographic improvement. The findings supported a diagnosis of imatinib-induced pneumonitis coexisting with tracheobronchial amyloidosis. Discussion This case highlights the diagnostic challenges when drug-induced pneumonitis occurs along with structural airway abnormalities. Tracheobronchial amyloidosis, although rare, can cause airway obstruction and coexist with inflammatory lung conditions. The temporal association with imatinib, exclusion of infection, and steroid responsiveness indicate imatinib-induced pneumonitis as the primary cause of the acute symptoms, with concurrent amyloid deposition contributing to airway pathology. Conclusion In patients developing new pulmonary symptoms after starting tyrosine kinase inhibitors, drug-induced pneumonitis should be strongly suspected. The coexistence of airway diseases such as tracheobronchial amyloidosis can complicate diagnosis and management, highlighting the need for thorough evaluation including bronchoscopy and tissue biopsy to guide treatment. This abstract is funded by: None