Management of Massive Airway Hemorrhage
Massive Hemoptysis – many definitions but better measured by the magnitude of the functional effects of the hemoptysis rather than the amount. What is the current clinical impact on the patient?
- Need for Hospitalization
- Need for Intubation
- Need for Transfusion
- Degree of hypoxemia and hypotension
- Proximal airway bleeding – malignant tumors(by far most common). Important to identify because interventional pulmonary techniques are very useful, and a rigid bronchoscope reaches this area, making it the instrument of choice
2. Distal airway bleeding – Many causes, virtually every lung pathology can lead to bleeding. Implications – bleeding cannot always be managed by interventional pulmonary methods
Techniques for lung isolation
It can be enticing to place a double lumen tube for the purpose of lung isolation and contralateral lung protection. However a double lumen tube so limits the ability to visualize and suction large amounts of blood and clot, that it can be detrimental to the patient. Fortunately other options exist. A bronchial blocker or Fogarty catheter with a split connecter/Arndt adapter are very useful and do not limit visualization and ability to suction with large caliber endoscope.
Note: A 3.8mm endoscope and a bronchial blocker can actually fit down a 7.0 fr ET tube, if this the largest that can be placed.
Assemble the system first – placing the Fogarty catheter with slight bend at the tip, and bronchoscope through the split adapter first, and test the balloon. The Fogarty catheter should be advanced slightly further than the scope. Disconnect the circuit and place the blocker and scope through the ET tube, and advance into the trachea, then attach the ventilator and resume ventilations. Begin advancing the Fogarty catheter and rotating and/or nudging in into the suspected bleeding airway. Slowly under visualization, begin inflating balloon. Advance Fogarty catheter as you inflate to keep it from dislodging.
Once in place and bleeding controlled, sedation of the patient is critical, and limited manipulation of the tube and patient is critical. I leave in place perform the first deflation test at 12-18 hrs under bronchoscopic visualization, giving time for correction of coagulopathy, and stabilization of respiratory status. I usually re-inflate and keep for another 6-12 hrs.