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Thoracic and vascular04 / 11

Massive haemoptysis for bronchial artery embolisation47-year-old man, 70 kg, known bronchiectasis

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Know this first

  • Over 600 mL in 24 hours is massive haemoptysis; asphyxia kills before blood loss.
  • Order: isolate the lung, resuscitate, find the source, treat it.
  • A double-lumen tube isolates fast, but its narrow lumens clog with clot.
  • A single-lumen tube can be pushed into the right main bronchus to protect that lung.

The patient

47-year-old man, 70 kg, known bronchiectasis, for emergency bronchial artery embolisation in interventional radiology. About 700 mL of blood coughed up in 24 hours; CT shows the bleeding is from the left lower lobe. Anxious, coughing fresh blood; no anticoagulants or antiplatelets. Vitals: BP 104/66, HR 118, SpO2 91% on 15 L reservoir mask, RR 28. Hb 9.6 g/dL.

The examiner asks

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  1. Consider

    What are your priorities?

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    • A 47-year-old with bronchiectasis and massive haemoptysis from the left lower lobe, for emergency embolisation in radiology. Patient
    • Over 600 mL in 24 hours is massive; asphyxia, not blood loss, is what kills him. Disease
    • Four steps in order: isolate the lung, resuscitate, find the source, then treat it.
    • Remote site with a sick patient, so I bring my own team, drugs and airway kit. Surgery

  2. Prepare

    What do you set up in the radiology suite?

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    • Bleeding side down: left lateral, so blood stays out of his right lung. Disease
    • Two large-bore cannulas, blood crossmatched, and the major haemorrhage protocol warned.
    • Tranexamic acid may be considered as an adjunct.
    • Kit: large single-lumen tube, double-lumen tube, bronchial blocker, bronchoscope and two suctions. Airway
    • Rigid bronchoscope and thoracic surgeon aware in case radiology can't stop it. Surgery

  3. Plan

    How will you secure his airway?

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    • Rapid sequence induction with suction running: ketamine 2 mg/kg, then rocuronium at 1.2 mg/kg. (Airway)
    • A large single-lumen tube first, for suction and an adult bronchoscope.
    • Ready to isolate: advance it into the right main bronchus to wall off the right lung.
    • Alternatively a blocker in the left main bronchus, placed by bronchoscope if the view allows.
    • A double-lumen tube isolates fastest, but clot blocks its narrow lumens.
    • No jet ventilation: dry gas under pressure solidifies blood and worsens obstruction.

  4. Crisis

    During embolisation blood wells up his tube; SpO2 falls to 78%, BP 88/56. What do you do?

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    • The left lung is flooding the right: tilt left side down if the table allows, 100% oxygen, suction. Crisis
    • Push the tube down the right main bronchus and seal it there.
    • Confirm by listening; bronchoscopy helps little in torrential bleeding.
    • Still flooding: rigid bronchoscope to clear clot and place a blocker in the left bronchus.
    • Major haemorrhage protocol activated; cells, plasma and platelets given near 1:1:1.
    • Radiology finishes the embolisation; that is the definitive treatment. After surgery

  5. Crisis

    Two hours after embolisation he is extubated but cannot move his legs. BP 112/70. What do you do?

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    • New paraplegia after arterial embolisation: I treat it as spinal cord ischaemia until proven otherwise. Crisis
    • Raise his mean pressure; hypotension worsens a cord with marginal supply.
    • Urgent MRI of the spine, and radiology and neurology called now.
    • CSF drain discussed with neurology; the evidence is from aortic repair, not embolisation.
    • ICU with frequent neurological checks and his pressure kept up. After surgery

Fatal mistakes

  • Positioning him with the bleeding side up.
  • A small tube that prevents suction and bronchoscopy.
  • No lung isolation plan before the remote procedure.
  • Jet ventilation into a bleeding airway.

Checked against: Miller 10e · Faust · Barash 9e

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Same topic, another patient

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Another patient · Intra-operative crises. Massive haemoptysis in interventional radiology. Same massive haemoptysis: airway floods at laryngoscopy, shock after isolation

Know this first

  • Massive haemoptysis kills by asphyxia, not by blood loss.
  • Four steps in sequence: isolate the lung, resuscitate, locate the source, then treat it.
  • Isolation by double-lumen tube, single-lumen tube into a bronchus, or bronchial blocker; place by clinical signs.
  • Bleeding lung down (dependent) until it is isolated.

The patient

24-year-old man, 58 kg, for bronchial artery embolisation in interventional radiology. Cystic bronchiectasis with recurrent infections; coughing bright blood since last night, CT pointing to the right lower lobe. Drugs: nebulised colistin, azithromycin. Vitals: BP 104/62, HR 118, SpO2 90% on 15 L/min, RR 28, Hb 9.6 g/dL.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 24-year-old with bronchiectasis bleeding from his right lower lobe, for embolisation in radiology. Patient
    • The threat is drowning: asphyxia kills quickly, long before he bleeds out. Disease
    • My order: isolate his lung, resuscitate, find the source, then the radiologist treats it.
    • Radiology is a remote site: less space and help, so my senior and full airway kit come. Surgery
    • His secretions are thick, plus clot; two strong suckers ready. Disease

  2. Plan

    How will you secure his airway?

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    • Right side down, so blood stays in the bleeding lung and spares the left. (Airway)
    • Preoxygenate, then rapid sequence: ketamine 1–2 mg/kg and rocuronium 1.2 mg/kg.
    • First a large single-lumen tube, so I can oxygenate and suction through it.
    • Then isolation: a double-lumen tube gives fast, secure separation, but its lumens suction poorly.
    • Fibreoptic views are poor in torrential bleeding; I confirm isolation by listening.

  3. Crisis

    At laryngoscopy, blood floods the airway and SpO2 falls to 72%. What do you do?

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    • Flooded airway: suction hard, keep his right side down, and get the tube in. (Crisis)
    • Advance the uncut single-lumen tube into his left main bronchus, turned 90 degrees anticlockwise.
    • 100% oxygen to his clean left lung only.
    • Or a bronchial blocker into the right main bronchus, which it enters easily.
    • Once he's stable, swap to a double-lumen tube over an exchanger if needed.

  4. Crisis

    After isolation, BP is 70/38, HR 140, and peak pressure 38 cmH2O. What do you do?

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    • Hypotension after isolation: blood loss plus positive pressure cutting his venous return. Crisis
    • Check the tube hasn't moved and blocked a lobe of his good lung.
    • Fluids and blood now, with the massive transfusion protocol ready.
    • Lower tidal volume to bring his airway pressure down.
    • Exclude a pneumothorax on the ventilated side.
    • Embolisation now; it's what stops his bleeding.
    • Afterwards he goes to ICU, still isolated and ventilated. After surgery

Fatal mistakes

  • No lung isolation in his massive haemoptysis.
  • His bleeding lung placed uppermost before it's isolated.
  • A tube too small to suction through.

Checked against: Miller 10e · Faust · Barash 9e

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