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Massive Hemoptysis

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Massive hemoptysis (MH) is a medical emergency that places the patient at risk of death. MH can be defined as the volume of expectorated blood that is life-threatening mainly by causing airway obstruction and rarely by severe blood loss. By consensus, MH is defined as a rate of bleeding exceeding 600 mL/24 h.

Because of the explosive clinical presentation of MH, it is essential to respond quickly and appropriately. Urgent management focuses on the prevention of asphyxia while the source of bleeding is addressed. Decision-making is a multidisciplinary process involving a critical care physician, a pulmonary medicine bronchoscopist, an interventional radiologist, a thoracic surgeon, and an anesthesiologist.

Bronchial artery embolization is now the treatment of choice.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Quebec – Université Laval, Quebec City, QC, Canada

    Jean S. Bussières

  2. Department of Anesthesiology and Critical Care, Université Laval, Quebec City, QC, Canada

    Marili Frenette

Authors
  1. Jean S. Bussières
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Corresponding author

Correspondence to Jean S. Bussières .

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Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

A 26-year-old woman is well known in the authors’ institution for Eisenmenger’s syndrome secondary to a complex congenital heart disease. She had a patent ductus arteriosus for which no surgical option was available when diagnosed at 4 years old. She was referred to our center 4 years ago for pulmonary hypertension. At that time, it was observed that the right pulmonary artery originates directly from the aorta. She has been treated with epoprostenol (Flolan) for 3 years.

A few months ago, she presented some episodes of moderate hemoptysis treated with BAE. Someday, she presented a new moderate hemoptysis necessitating BAE. She was admitted to the intensive care unit for 5 days, and no bleeding was observed. She was then transferred to the bronchoscopy suite to search for a blood occluding the right inferior lobe bronchus. With the aid of sedation and local anesthesia, the area was easily reached. The blood clot was partially dislodged without any problem. While trying to dislodge the remaining of the clot, coughing was provoked, and it induced a massive bleeding from the inferior lobe.

Questions

Which immediate procedure should be undertaken?

  1. 1.

    Nasal oxygen was already in place for the FOB exam.

  2. 2.

    Right lateral decubitus position to protect the left lung from blood spillage.

  3. 3.

    Irrigation of the origin of bleeding with cold saline.

Bleeding continues and becomes a MH. What is the next step?

  1. 4.

    Left-side endobronchial intubation with single-lumen tube with the assistance of the FOB.

  2. 5.

    Left lateral decubitus position to improve left lung gas exchange and minimize bleeding from the right lung.

  3. 6.

    Exchange the endobronchial simple lumen tube for a double-lumen tube.

The patient was directed, with anesthesia assistance, to the radiological suite for angiography and BAE as needed. Following diagnostic angiography and therapeutic embolization, the radiologist wanted to know about the bleeding in the right lung. What we can do to help her?

  1. 7.

    Fiber-Optic Bronchoscopy Examination

Following this procedure, the right-side bronchial tree was suctioned. At that time, active bleeding was identified originating from the right inferior super dorsal bronchus. Following a new BAE, the bleeding ceased, and the cleaning of the bilateral bronchial tree was completed without finding any other bleeding site.

The patient was transferred to the ICU with the DLT in place. She was sedated and ventilated until the next morning when she was extubated. She did not present any recurrence, and she was transferred to another center for evaluation for lung transplantation.

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Bussières, J.S., Frenette, M. (2019). Massive Hemoptysis. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_44

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_44

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