Hemoptysis

Airway first, and fast - The decision to intubate has to be made quickly: a tube protects the airway and lets you oxygenate and ventilate the remaining functional lung. Call the thoracic surgeon at the same time you call for help — control of the airway is the whole game.

Localize the bleeding side - Lung exam for unilateral findings, a frontal chest radiograph looking for a unilateral source, and CT, which may be more sensitive than bronchoscopy and is considered first-line by some. You cannot isolate what you have not localized.

Bleeding side down - Once you know the side, put it dependent to keep blood out of the good lung. Trendelenburg or reverse Trendelenburg helps. If the left lung is bleeding and no scope is available, right lateral decubitus shifts the mediastinum to the right.

Think twice about a double-lumen tube - DLTs are generally not recommended in massive hemoptysis: the bronchoscope that fits down them has no suction channel adequate for blood, only a pediatric scope passes, the proximal airway can't be inspected, and placement is slow and takes expertise you may not be able to assemble in a crisis.

Bronchial blocker - This is the workhorse: it ventilates the clear lung while tamponading the bleeding side. Place it with fiberoptic assistance through the ETT into the mainstem or bronchus intermedius. With no commercial device, a Fogarty catheter through the fiberoptic scope channel or alongside the ETT has been used.

Mainstem intubation as a bailout - With uncontrolled bleeding, intubate the right mainstem. Intubate the trachea, rotate the tube 90 degrees toward the target side, and advance to resistance — 94% successful for the right and 72.3% for the left in a cadaver study. A 5.0 mm ETT down the right mainstem either ventilates or isolates that lung and still leaves room to pass a second tube to the left.

Fiberoptic bronchoscopy earns its keep - It finds the source, clears blood and clots from the non-bleeding lung, guides intubation of the non-bleeding lung, and can be wedged into the bleeding site to tamponade. Rigid bronchoscopy does all of that while ventilating, and its large channels take extra suction catheters plus the flexible scope.

Plan for a soiled airway - Keep two suction setups running; SALAD and double-suction techniques exist for exactly this. Type and crossmatch and confirm blood is in the building before an elective procedure on a patient who may bleed into their lung.

Definitive treatment is embolization - Bronchial artery embolization is often first-line, since the bronchial system is the source about 90% of the time; anterior spinal artery embolization complicates 0 to 1% of cases. Resection is a last resort — emergent resection carries 35% mortality versus 4% when scheduled after hemostasis, so temporize if you possibly can.

Intrabronchial temporizing measures - Cold saline lavage, epinephrine injection, endobronchial spigots, cellulose mesh, and ADH derivatives via flexible or rigid scope. If the source is visible and reachable, electrocautery, cryotherapy, laser, and argon plasma coagulation are options.

Postoperative course - Expect to leave the trachea intubated. Pulmonary hygiene with chest physiotherapy, lavage, and suctioning continues in the ICU, and ongoing coughing that re-provokes bleeding is an indication for sedation and pharmacologic paralysis.

Hemoptysis is bleeding from the pulmonary or bronchial vasculature coughed out of the lower airway. The bronchial circulation is a systemic, high-pressure bed and is the culprit in up to 90% of massive bleeds; pulmonary vessels and other non-bronchial systemic sources account for about 5% each, with aortobronchial fistula and ruptured aneurysm among the rest. Definitions based on volume run from 100 to 200 mL, and the number is nearly impossible to measure at the bedside.

What kills is asphyxia, not exsanguination — blood floods the alveoli of the lung that still works and gas exchange stops. Before bronchial artery embolization, mortality approaches 70%.