Citations

Abstract Rationale High and intermediate risk pulmonary embolism (PE) contributes significantly to in hospital morbidity and 5-10% of in hospital deaths. Thrombolytic therapy either via systemic intravenous tissue plasminogen activator (IV-tPA) or catheter directed thrombolysis (CDT) remains central to management, however, comparative national data on utilization and outcomes of thrombolytic therapy for PE remain limited. Methods Using the National Inpatient Sample data from 2010 to 2021, adult hospitalizations for acute PE were identified using ICD 9 code 415.1 and ICD 10 code I26. Cases receiving IV-tPA or CDT were identified using procedural codes. Temporal trends, in-hospital mortality, length of stay (LOS) and complications were compared between treatment groups using weighted analyses. Results Among 1,940,718 hospitalizations with acute pulmonary embolism, the use of thrombolytic therapy increased from 2010 to 2021 for both systemic intravenous tissue plasminogen activator (IV-tPA) and catheter-directed thrombolysis (CDT). Utilization of IV-tPA rose from 1.8% to 2.%, while CDT increased from 1.4% to 3.9%. Compared to IV-tPA, patients treated with CDT were more likely to be older (42.7% vs 39.3% were aged 65 years or above) and male (50.8% vs 48.7%). CDT was associated with significantly lower in hospital mortality (6.7% versus 11.1%, p < 0.01), shorter median length of stay (5 versus 6 days, p < 0.01) and fewer discharges to facilities (13.7% versus 19.4 %, p < 0.01). Rates of major complications were lower in the CDT group, including intracranial hemorrhage (0.4% versus 1.2%), cardiac arrest (1.7% versus 7.3%), myocardial infarction (4.7% versus 5.1%) and need for mechanical ventilation (6.7% versus 16.1%). However, use of extracorporeal membrane oxygenation (0.7% versus 0.2 %) and surgical embolectomy (1.2% versus 0.7%) was higher among CDT patients. Conclusions From 2010 to 2021, utilization of thrombolytic therapy, particularly catheter-directed techniques increased among PE hospitalizations. CDT was associated with lower in hospital mortality, shorter stays and fewer complications compared to systemic IV-tPA. These findings support the expanding role of catheter based interventions as a preferred therapeutic approach for patients with high and intermediate risk pulmonary embolism. Further prospective studies are warranted to confirm long term outcomes and optimize patient selection for CDT. This abstract is funded by: None

Abstract Introduction Mediastinal masses encompass broad differentials of reactive, inflammatory, infectious or neoplastic etiology. In the background of extra thoracic malignancy, it raises a high suspicion for primary cancer or metastatic lymphadenopathy. However, a benign anatomical variant can mimic these findings and lead to unnecessary diagnostic procedures and patient anxiety. Recognizing mimickers becomes crucial in avoiding misdiagnosis and overtreatment. Case A 50-year-old woman with no significant past medical history presented with a two-day history of headache, associated with cough, orthopnea and lower extremity edema. Vital signs were significant for elevated blood pressure at 199/107 mm Hg. Laboratory findings noted a markedly elevated B-type natriuretic peptide (19,000 pg/mL), increased serum creatinine (1.4 mg/dL from baseline 0.7 mg/dL) and proteinuria. Chest X-ray revealed pulmonary vascular congestion. Autoimmune serologies were positive for antinuclear antibody (titer 1:2560), ribonucleoprotein antibody, and RNA polymerase III antibody. Renal biopsy confirmed scleroderma renal crisis. She was treated for hypertensive emergency secondary to scleroderma renal crisis. Further evaluation for elevated total protein revealed monoclonal gammopathy on electrophoresis and 30% plasma cells on bone marrow biopsy, consistent with smoldering multiple myeloma. A chest computed tomography scan incidentally identified a 4 × 3 cm lobular right paratracheal mass. Tissue biopsy was requested to exclude plasmacytoma. Bronchoscopy with endobronchial ultrasound revealed a large hypoechoic paratracheal lesion. Biopsy was aborted due to its cystic appearance and risk of airway flooding. Subsequent magnetic resonance imaging was obtained for tissue characterization which delineated the mass as a thin walled, fluid filled structure communicating with the superior aortic recess, consistent with a high riding superior pericardial recess which is a benign anatomical variant. She was discharged with plans for outpatient multidisciplinary follow up, including pulmonary evaluation for interstitial lung disease surveillance. Discussion High riding pericardial recess is a benign anatomical variant which can closely mimic pathologic masses or lymphadenopathy on cross sectional imaging. Key is identification of probable communication with the superior aortic recess associated with fluid attenuation. Knowledge of anatomy, comprehensive multimodal imaging review, and multidisciplinary discussion are key to prevent unnecessary investigation of mediastinal abnormalities. This abstract is funded by: None

Abstract Rationale Endobronchial valve (EBV) placement is an established bronchoscopic lung volume reduction (BLVR) therapy for advanced emphysema. Although randomized trials have shown improvements in lung function, real-world data on predictors of response and complications remain limited. This study evaluated physiological and clinical outcomes after EBV placement and explored predictors of treatment response and adverse events. Methods We retrospectively analyzed 75 patients who underwent EBV placement for severe emphysema at Mayo Clinic Florida between 2018 and 2023. Demographics, comorbidities, pulmonary function test and complications data were collected before and after procedure. Responders were defined as those achieving a ≥ 15% relative increase in forced expiratory volume in one second (FEV1), ≥10% reduction in residual volume (RV), ≥25-meter increase in six-minute walk distance (6MWD), or ≥ 1-point decrease in modified Medical Research Council (mMRC) dyspnea score. Results The mean age was 70.4 ± 7.1 years, 59% were female, and the mean Body Mass Index was 25.6 ± 4.9 kg/m². Most patients were non-Hispanic White (96%) and ever-smokers (97%, median 40 pack-years). Following EBV placement, FEV1 increased by + 0.10 L (p < 0.001), forced vital capacity by + 0.17 L (p = 0.001), RV decreased by -0.69 L (p < 0.001), while total lung capacity decreased by -0.35 L (p < 0.001). Diffusing capacity, 6MWD, and mMRC did not significantly change. Responder analysis showed FEV1 improvement in 52% (34/65), RV reduction in 65% (42/65), 6MWD gain in 33% (18/55), and mMRC improvement in 33% (21/63). Complete lobar atelectasis occurred in 59% (44/75) and was significantly associated with FEV1 improvement (p < 0.01). 30-day follow up complications included pneumothorax (26.7%), COPD exacerbation (21%), and pneumonia (20%). 15% pneumothoraces were managed conservatively, 55% required chest tube, 30% needed valve removal due to persistent air leak. Valve migration and replacement occurred in 2.6% each, and valve removal in 26.6% patients. Median hospital stay was longer in patients with complications (5 vs 4 days, p = 0.003). In-hospital mortality was 5.3% but no procedure-related deaths were identified. Conclusions EBV placement is a safe and effective BLVR approach yielding significant improvements in FEV1 and reductions in hyperinflation. Pneumothorax and valve-related events were the most frequent complications. Complete lobar atelectasis strongly correlated with functional improvement, suggesting that early reassessment should be considered when collapse is not achieved to prevent complications and unnecessary valve retention. This abstract is funded by: None

Abstract Rationale Advances in bronchoscopic technology, including robotic-assisted bronchoscopy (RaB) and cone-beam CT (CBCT), have enabled biopsy of multiple nodules in a single procedure. Here we present the procedural characteristics, safety, diagnostic yield, and use of linear endobronchial ultrasound (EBUS) staging in patients with multifocal pulmonary nodules biopsied under a single anesthesia event. Methods This multi-center, retrospective observational study included adults undergoing RaB biopsy of multifocal peripheral pulmonary lesions and lymph node assessment under a single anesthesia event at six U.S. centers from 11/2019 - 8/2025. Procedures utilized either the Ion (Intuitive) or Monarch (Ethicon) systems under general anesthesia. De-identified demographic, radiologic, procedural, pathologic, and safety data were collected in a secure centralized database. Safety outcomes included pneumothorax and its sequelae, hypoxia, and infectious complications. Diagnostic yield was determined using the 2024 ATS/ACCP consensus statement. NGS adequacy was reported from two health systems with well-defined criteria for sufficiency and standard institutional practices for sending NGS testing on both nodules. Statistical analyses utilized included descriptive statistics, t-tests, chi-squared/Fisher’s tests where appropriate, and logistic regression. Results Among 191 patients, 177 underwent biopsy of two and 14 of three nodules. Lymph nodes were sampled in 167 (87.4%), with 18 (10.8%) positive for malignancy; notably, 17 of 18 (94%) patients with nodal metastases had at least one fully solid nodule. Complications occurred in 20 patients (10.5%), including pneumothorax in 14 (7.3%), with 4 (2.1%) requiring tube thoracostomy. There were no cases of bilateral pneumothorax. Transient hypoxia occurred in 3 patients (1.6%) and 3 developed outpatient-managed bronchitis. Seven patients (3.7%) required unplanned admission. Overall diagnostic yield was 72.2%, with 122 (63.9%) patients having two diagnostic nodules and 33 (17.4%) having two non-diagnostic nodules. Bronchus sign (OR 2.9, p = 0.003), radial EBUS use (OR 2.6, p = 0.025), and CBCT use (OR 2.4, p = 0.021) were associated with procedures having two diagnostic nodules. At sites with standardized NGS adequacy reporting, 74 of 81 malignant nodules (91%) provided sufficient tissue for NGS. Conclusions •Single-procedure biopsy of multifocal pulmonary nodules is feasible, safe, and achieves industry-standard strict diagnostic yield. •Complications are slightly higher than single-nodule procedures. Serious events were rare. •17 of 18 patients with malignant nodal disease had at least one fully solid nodule; no patients with two pure ground glass nodules had nodal metastasis. •NGS testing was feasible and adequate on the majority of samples, aiding clinicians in staging multifocal nodules. This abstract is funded by: None

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