P075: MANAGEMENT OF "CAN INTUBATE, CANNOT VENTILATE" CRISIS IN LIFE-THREATENING HEMOPTYSIS
Camila Magalhaes Funatsu, MD; Aparna Yarram, MD; Danielle Esnard, MD; Alexander Harrington, MD; Bianca Flores, RN
Jackson Health System / University of Miami
Introduction/Background: Hemoptysis, the expectoration of blood from the lower respiratory tract, is a sign of lung disease. Massive hemoptysis, occurring in less than 5% of cases, is a medical emergency due to its potential to cause asphyxiation by flooding the tracheobronchial tree. Although the definition of massive hemoptysis varies in the literature, the range of 200–1000 mL in 24 hours has been noted as the anatomic dead space of the tracheobronchial tree approximates 200 mL, and impaired oxygenation can ensue when approximately 400ml of blood is in the alveolar space.
Case Report: This case describes a 49-year-old female with metastatic angiosarcoma to lung and bones and treatment-related AML complicated by Aspergillosis. Airway team was called for emergency intubation due to severe hypoxia from massive hemoptysis. After suctioning the oropharynx and endotracheal tube (ETT) with minimal oxygenation improvement, patient was transferred to the ICU.
A bedside bronchoscopy revealed that the right main bronchus was the source of the bleeding. Attempts to isolate the left main bronchus for one-lung ventilation were abandoned due to ongoing bleeding. The ETT was positioned 3 cm above the carina, and the patient was taken emergently to interventional radiology (IR) suite for bronchial embolization.
Post-procedure, the patient remained hypoxic with low tidal volumes and high peak airway pressures. The ECMO team deemed the patient ineligible due to high-grade cancer. Due to continued critical status, patient was unable to be transported out of IR suite.
Interventional pulmonology was consulted for clot removal, and the patient’s 7.0 ETT was replaced with an 8.0 ETT. The first attempt was made with the removal of existing ETT and visualization with direct laryngoscopy due to concern for active bleeding. However, after placement of the larger ETT, we could not ventilate the patient and confirm the correct placement with end-tidal CO2. The ETT was replaced once again under video laryngoscopy that showed appropriate placement into the trachea but with continued inability to ventilate the patient.
At this point, the ETT was left in place, and a flexible bronchoscope was placed into the 8.0 ETT, which showed an obstructing clot at the end of the ETT, preventing ventilation. After suctioning and partially displacing the clot into the right main bronchus, ventilation improved, and end-tidal CO2 confirmation was achieved. An endotracheal blocker was placed in the right lung and patient was transferred to the ICU.
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After 36 hours, bronchoscopy indicated that bleeding was controlled, allowing for the restart of two-lung ventilation.
Conclusion: Management of massive hemoptysis requires prompt recognition and multidisciplinary approach to optimize outcomes. Despite availability of appropriate supplies, staffing, specialized services, and advanced airway skills such as flexible fiberoptics, unique challenges arise with massive hemoptysis rendering interventions ineffective. Most airway management algorithms rely on direct or indirect visualization of the glottis, which may be inadequate in a bleeding airway. In this case report, a fiberoptic bronchoscope was employed to confirm correct positioning ETT and facilitate clot removal, enhancing the patient’s oxygenation.