UMEM Educational Pearls

Title: Pearls for the Patient with Massive Hemoptysis

Posted: 5/24/2022 by Caleb Chan, MD
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-If the patient is able to maintain mentation/airway/SpO2/hemodynamics and cough up blood, intubation is not immediately necessary

an ETT will actually reduce the diameter of the airway and can impede clearance and precipitate respiratory failure

-If you do intubate, intubate with the largest ETT possibly to faciliate bronchoscopic interventions and clearance of blood

Men: 8.5 or above; Women: 8.0 or above

-The CT scan that typically needs to be ordered is a CTA (not CTPA) with IV con

90% of life-threatening hemoptysis from the bronchial arteries

-See if you can find prior/recent imaging in the immediate setting (e.g. pre-existing mass/cavitation on R/L/upper/lower lobes)

having a level of suspicion for location/lateralization is helpful for the performing bronchoscopist to allow them to empirically occlude a location with an endobronchial blocker in a crashing hypoxemic patient if visualization is difficult 2/2 blood

-Get these meds ready before the bronchoscopist gets to the bedside to expedite care:

iced/cold saline, thrombin, code-dose epi (which will be diluted)
there is also some (not great) data for intravenous TXA and improved outcomes

-If the pt's vent suddenly has new high peak pressures or decreased volumes after placement of endobronchial blocker, be concerned that the blocker has migrated

this can happen even with 1 cm movement of the ETT or blocker, or extension of the patient's neck
know where the ETT is secured as well as the endobronchial blocker (analagous to locking of a transvenous pacer)
pts with endobronchial blockers should also be on continuous neuromuscular blockade

References

Charya AV, Holden VK, Pickering EM. Management of life-threatening hemoptysis in the ICU. J Thorac Dis. 2021;13(8):5139-5158.