Today, I am joined by my buddy and pulmonary-critical care stud, Oren Friedman, to discuss the management of Massive Hemoptysis
See More from Oren
Some Basics on Massive Hemoptysis
- LitFL
- First10 EM
- Review by Sakkour on Massive Hemoptysis
- IBCC chapter Severe hemoptysis
- A Wee Bit More on Massive Hemoptysis
Intubate Big
Localize
C-XR, chart review, and initial bronch. Remember Oren's tip: if you get in there and can't find any bleeding, temporarily disconnect the vent
Is it Amenable to Bronch Treatment?
If not, Block; preferably at the segmental level
Use a bronchial blocker, not a double lumen tube
Uni Blocker
EZ Blocker
A poor 2nd choice is mainstem intubation
Then Get a CTA of the Chest
Then go to IR for Bronchial Artery Embolization
95% of the lesions will arrise from the bronchial circulation. The ones that don't are PE, Pulmonary Art Catheter mishaps, and AVMs of the Pulmonary arterial circulation.
If that fails, Surgery or ECMO
Updates
- Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026.
- Great Review Article from CHEST
Now, On to the Podcast…
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An ED Intensivist from NY. No conflicts of interest (coi).
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[…] Management of Massive Hemoptysis EMCrit by Scott Weingart. Continue Reading → […]
Oren, you forgot about APC! Argon plasma coagulation. I learned about this gem from one of the IP guys working with thoracic surgery at Cornell (after Oren had already left us for Cedars). I prefer APC to cautery – you do not have to make direct contact with the mucosa, so there’s no risk of peeling off the charred tissue and causing more bleeding. There’s still the risk of airway fire, so need low O2 environment. The GI guys use this all the time, so it’s pretty easy to get in the hospital. It’s also NOT a laser, so no… Read more »
Great addition Mae — the rise of APC capability came at the end of my tenure there so i never got my hands on it . As you point out is an excellent addition . Its availability form institution to institution however will vary. I think it is important for everyone to remember that a bronch for massive hemoptysis should not be considered akin to an EGD for upper GI bleeding — the likelihood that you can directly fix the bleed with bronch the way you can with EGD is much much lower, and many institutions will not have IP… Read more »
How exactly was the Amicar used?
topical
1g per 10 cc
wash into the segment that is bleeding
TXA and/or endobronchial Epi are other great options along with chilled/ice saline.
How do you connect a syringe, such as iced saline or phenylephrine premixed, with a luer lock to the injection port of a bronchoscope?
2 choices
put an 18 or 16g angio through the rubber port, i put a luer cap on top and tape it there
or advance an epidural cath down the channel
First of all best to have a NON luer lock syringe this is much easier to work with through the working channel of the scope HOWEVER , you can convert a luer lock to a non by simply taking some trauma shears, applying pressure around the lock and spinning the syringe — what will happen is the screw part will cut away leaving you with a nice non-lock to administer stuff through the scope. Different scope brands have different attachments for the syringe — for example it is very hard to work with an Olympus without a non luer lock… Read more »
George Kovacs Great discussion. Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations: Call for help 1. Patients with massive pulmonary hemorrhage die. Respect hemoptysis especially related to tumors or scenarios where there is an erosion into a vessel. They’re ok until they’re not and then its often too late, 2. Send someone to the chart/x-ray to get info as to which side the pathology is on 3. Raising the bed will help allow you to lift the epiglottis out of the… Read more »
Not sure if I’m more grateful for all the great clinical tips, or that you’ve turned me onto a new great metal band. Thanks for both
Thank you for this episode! what exactly is your thought process on R main stem intubation? I have actually done this before on a pt who coded and then, started with massive hemoptysis- (no known specific cause), Hemorrhaging out the ETT, so i placed it main stem and the hemorrhaging (at least visibly out of the ETT) stopped, and i was able to ventilate. My thinking may not be exactly yours, so just wondering why you recommend Main stem tube and then what would you recommend (especially if you don’t have a bronchoscope in a rural ED)? Thank you for… Read more »
Looks like this was mostly answered above by George. I should have refreshed before sending!
I’m PMCC train and in proficient with a bronch in my hands.I already read the posts below (A few days early they will have come in handy) but I want to share a case and some possible tips for young guys like me in areas with no IP or Thoracic surgeons. A few days ago I had a case of massive hemoptysis due to NTM infection. Pt arrested and was intubated before I got to the ER. A decent tube was in place and I bronched the the pt with T scope, The pt was bleeding from the right lung… Read more »
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[…] Episode 199 Management of Massive Hemoptysis with Oren Friedman and A Wee Bit More on Massive […]