Division of Pulmonary and Critical Care Medicine Posters

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  A Follow-up to Implementing a Sizing Chart for Nasal Cannula Placement to Decrease Associated Pressure Ulcers in Infants

  William F. Bucher, RRT-NPS

  Background

  The Joint commission definition of a “Pressure Ulcer” is a broader term that includes decubitus ulcers, but also includes any ulcerations associated with pressure. In 2015, over a three-month period, the Intensive Care Nursery (ICN) at Thomas Jefferson University Hospital had five patients who developed pressure ulcers due to placement of an improper size nasal cannula being used for that patient. Infant nasal cannulas are typically classified as being for micro premature, premature, neonate, infant, and intermediate infant size patients. To this day, there is no instruction by most manufactures for fitting a nasal cannula to the actual size of the patient in kilograms. Also, cannulas are not of a universal size from various manufacturers.

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  Bronchoalveolar Lavage Neutrophils and Matrix Metalloproteinase-9 in Sarcoidosis Clinical Phenotypes: Implications for Tissue Remodeling Leading to Pulmonary Fibrosis

  Rafael L. Perez, MD; Jeff Ritzenthaler; E. Torres-Gonzalez; Prarthna Chandar, MD; Daniel Kramer, MD; and Jesse Roman, MD

  Introduction

  Pulmonary sarcoidosis may resolve or progress to advanced stages. Increased lung neutrophils obtained by bronchoalveolar lavage are found in advanced pulmonary sarcoidosis. Persistence of a neutrophilic alveolitis has been postulated to result in tissue injury and remodeling that leads to fibrosis and clinical features of advanced disease. Since neutrophils are a source of matrix-degrading proteins like matrix metalloproteinases (MMPs), we hypothesized that PMNs promote disease progression through the release of MMPs. This work explores the relationship between lung neutrophils and MMP9 levels and activity and how they are associated with sarcoidosis clinical phenotypes.

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  Is NIPPV Superior to CPAP in Maintaining Targeted Oxygen Saturation Ranges in Preterm Infants on Moderate Non-Invasive Respiratory Support?

  Clifford Hegedus; William F. Bucher, BS, RRT-NPS; David Carola; and Zubairul Aghai

  Background: Non-invasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP) are non-invasive respiratory supports commonly used in preterm infants. There is conflicting data on the superiority between these two modes of non-invasive respiratory support. The objective of this study was to determine if oxygen saturation is more within the target range on NIPPV compared to CPAP using the data from histograms.

  Methods: Retrospective analysis of premature neonates (< 1500 grams, gestational age < 30 weeks) admitted to the NICU for which oxygen saturation histogram data was available one day before and after the transition between NIPPV and CPAP. FiO2 at the time of data collection was greater than 21 percent. This histogram data, the percentage of time spent in certain SpO2 ranges, was compared before and after the de-escalation from NIPPV to CPAP or escalation from CPAP to NIPPV. FiO2 was additionally compared between the two modes of respiratory support.

  Results: A total of 26 infants were included. The median gestational age was 25.5 weeks and the median weight of the infants was 792 grams. Among the 26 infants, there were 34 episodes of transition between NIPPV and CPAP, 19 switches from NIPPV to CPAP, and 15 from CPAP to NIPPV. The percentage of time that oxygen saturation was within the target range (89-94 %) was not statistically significant between the two modes of respiratory support (CPAP 39.9% vs. NIPPV 43.9%, p=0.09) (Table 1). The percentage of time that oxygen saturation was between 86-88% was higher on NIPPV and the percentage of time that oxygen saturation was >94% was higher on CPAP. There was a trend towards lower FiO2 on NIPPV compared to CPAP. When switched from NIPPV to CPAP, there was a higher percentage of time spent above the target range ( >94%) while on CPAP (56% vs 49%, p=0.001), and below the target range (86-88%) while on NIPPV (5.0% vs 1.4%, p=0.02) (Table 3). When switched from CPAP to NIPPV, there was no difference in oxygen saturation ranges (Table 2).

  Conclusion: Target oxygen saturation ranges on histogram data were similar in premature infants when supported on CPAP and NIPPV. However, oxygen saturation below the target range was more frequent on NIPPV compared to CPAP. NIPPV is not superior to CPAP in maintaining oxygen saturation within the target range in premature infants on moderate non-invasive respiratory support. The potential risk of low oxygen saturation range while supported on NIPPV in preterm infants requires further research.

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  Multidisciplinary Care for Adult Hermansky-Pudlak Syndrome Patients in Puerto Rico

  Isabel Becerra, Shirley Martinez, Atencio Xavier, Torrens Jonathan, Juan Alemany, Eric Cruz, Felix Rivera Borges, Monica Egozcue, Jesse Roman, and Rosa Roman

  Background: Hermansky-Pudlak syndrome (HPS) is an autosomal recessive rare disease characterized by oculo-cutaneous albinism, bleeding diathesis due to platelet dysfunction, and is sometimes accompanied by immunodeficiency, granulomatous colitis, and/or interstitial lung disease / pulmonary fibrosis. Puerto Rico houses the highest concentration of patients with HPS, especially HPS-1, which is considered quite severe and often associated with pulmonary fibrosis. We believe that the establishment of an HPS Multidisciplinary Clinic in Puerto Rico would improve outcomes.

  Methods: A multidisciplinary clinic was started in November 2018 and another was held in February 2019 at the Mayaguez Medical Center located in the Southwest region of the island. Pulmonologists, hematologists as well as gastroenterologists and a dentist staffed the clinic. Pulmonary function testing was available. Patients were identified by the HPS Network and other announcements.

  Results: Thirty-six patients were evaluated during the February 2019 clinic. Gender distribution was essentially equal and most patients were 50 years of age or younger. Fifty-eight percent classified themselves as having HPS-1 and 11% as having HPS-3, but the exact mutation was not known in 31%. Of the thirty patients obtaining pulmonary function tests, 60% showed abnormal force vital capacity (FVC) with 13% showing severe dysfunction. Thirty-one percent of patients had been treated for colitis, while 58% had bleeding at some point. Most patients had not received Influenza vaccination.

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  The Role of Diagnostic Bronchoscopy in Refractory Asthma Management

  Christopher McGrath, MD; Tuhina Raman, MD; and Jessica Most, MD

  Refractory asthma is an uncommon entity, manifesting in less than five percent of asthmatics and characterized by high medication requirements, persistent symptoms, frequent exacerbations, and significant airflow obstruction despite standard medical therapy.[1] Bronchoscopy may be an effective tool for identifying refractory asthma phenotypes.[3] The objective of this case series is to demonstrate the use of bronchoscopy to personalize treatment among a population of refractory asthmatics.

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  The In Vivo Effects of Alcohol in Lung and Liver are at Least Partially Mediated through the Alpha 4 Nicotinic Acetylcholine Receptor

  J. Ritzenthaler, E. Torres-Gonzalez, G. E. Arteel, and J. Roman

  Rational: Chronic alcohol abuse is a major risk factor for the development of acute lung injury, with 40% of annual cases in the U.S. linked to this disorder. Alcohol is not only associated with increased incidence of acute lung injury in at-risk individuals, but also increased mortality. The exact mechanisms by which alcohol abuse renders the host susceptible to acute lung injury remain poorly defined. We have reported that α4 nicotinic acetylcholine receptors (α4 nAChRs) may serve as potential sensors for alcohol in lung fibroblasts; however, we have not tested their role in vivo.

  Methods: To test the role of α4 nAChRs in mediating alcohol-related events in vivo, we generated α4 nAChR knockout (KO) animals in C57Bl/6 using Crispr/Cas technology. Wildtype (WT) and α4 nAChR knockout (α4 KO) animals were used to harvest primary lung fibroblasts for study in vitro. In vivo experiments included exposure to Lieber DeCarli isocaloric or Maltose-Dextrin control diet for 6 weeks.

  Results: Having ensured that the α4 KO animals indeed lacked the α4 nAChR, we isolated primary lung fibroblasts and evaluated their expression of the matrix glycoprotein fibronectin after exposure to nicotine (50 ug/ml) or alcohol (60 mM). As expected, nicotine induced fibronectin expression independent of the presence or absence of α4 nAChRs. In contrast, alcohol induced fibronectin mRNA expression in primary lung fibroblasts harvested from WT animals, but not from α4 KO animals. We then engaged in in vivo studies designed to examine the expression of specific genes in whole lung and liver; including the cysteine transporter Slc7a11 (which controls redox state), the pro-inflammatory cytokine TNFα (which has been implicated in alcohol-induced lung injury), and the protease inhibitor PAI-1, (which also appears involved in alcohol-related injury to lung and liver). No overt structural abnormalities were detected in the α4 KO animals. After 6 weeks of control or alcohol diets, lungs and livers were harvested and processed for mRNA evaluation. WT lungs and livers showed significant induction of all three mRNAs when exposed to alcohol, whereas the α4 KO animals showed little to no induction. Liver histology also showed evidence of increased steatosis in WT animals when compared to the α4 KO animals.

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  Evaluation of a Mechanical Ventilator Education Program for Intern Physicians in an Intensive Care Nursery

  William Bucher and Brian Glynn

  Background: Thomas Jefferson University Hospital is a large urban Academic Medical Center with a level III Intensive Care Nursery (ICN). A new group of pediatric interns rotate through the ICN every year and receive limited education on mechanical ventilation. We developed a live, one hour training session performed by a Respiratory Therapist and a Respiratory Challenge Test to be completed by the physicians before and after each session. Clinical training was defined as routine training acquired during daily rotation in the ICN. We hypothesized that classroom and clinical training would be more effective than clinical training alone.

  Method: After a one week clinical rotation, fourteen Pediatric Interns received a ten question, multiple-choice, written Respiratory Challenge Test followed by a one hour training session on mechanical ventilation. After the training session, the physicians received the same Respiratory Challenge Test and results were compared.

  Results: The average test score after clinical training alone was 57.1%. The average score following clinical coupled with classroom training was 72.9%. There was a 27.6% increase in test results following the one-hour training session (p= 0.0007).

  Conclusion: The development of a live, one hour classroom training session performed by a Respiratory Therapist has been proven to significantly improve test scores when compared to clinical training alone. We believe that this program will improve patient quality and safety in our Intensive Care Nursery.