#14 Massive Hemoptysis w/ Dr. Whittney Warren

PulmonaryGuest Episode
Written By Nick Mark

Hemoptysis can be a scary thing to encounter in medicine and massive hemoptysis - i.e. life threatening hemoptysis - is a serious emergency that often requires cognitive agility and technical prowess. Join Nick & Cyrus as they talk with Dr. Whittney Warren - an intensivist and interventional pulmonologist - who walks us through her pragmatic approach to life-threatening hemoptysis. What medications can we use to stabilize these patients? How would we go about intubating such a patient? What bronchoscopic tools do we have at our disposal? Listen to this first CCT episode of 2024 and find out! 

Infographic:

Check out this infographic from ICU OnePager for more about management of massive hemoptysis.


Show Notes:

Massive hemoptysis in 2024 shouldn’t be defined strictly by a volume, but rather, the extent to which a patient’s hemoptysis poses an imminent threat to life. Volume matters, but not as much as  the patient’s comorbid conditions & consequent physiologic reserve.

  1. Massive hemoptysis may be cryptogenic in as many as 50% of cases. Otherwise, consider infectious/inflammatory causes that result in airway / parenchymal distortion.

  2. Anatomically, the left and right bronchial arteries originate from the proximal descending thoracic aorta - either directly or off an aortic branch. These vessels or their branches are the culprit vessels in the setting of massive hemoptysis.

  3. ED clinicians and general pulmonologist/intensivists should feel comfortable stabilizing and managing massive hemoptysis - while interventional pulmonologists are ready, willing and able to lend their advanced skillset to these cases, securing the airway, clearing blood and temporizing a bleed do not require an interventionist! 

  4. Patients with hemoptysis rarely die of blood loss but far more frequently will succumb to asphyxiation due to airway compromise if they are unable to effectively clear their airway and maintain alveolar ventilation & oxygenation. A patient with shock and hemoptysis who does not have a better explanation for their shock is very worrisome!

  5. Assessing for coagulopathy should be part of your initial work up if there is concern for massive hemoptysis. Consider a coagulation panel, thromboelastography and a fibrinogen level to guide resuscitation / reversal of coagulopathy. If a patient is truly experiencing massive hemoptysis, consider anticoagulant reversal where relevant.

  6. Nebulized TXA (500mg in 5-10cc of NS, nebulized, with or without albuterol) can help temporize/tamponade a bleed and can be highly effective in patients who do not need a secure airway, or in those who have not demonstrated a need for one yet.

  7. When/if a patient is stable, a contrasted CT scan is the best test to assess for location of bleeding. Bronchoscopy can be very helpful in diagnosis and therapy, however, it is not as effective for localizing the vessel(s) or likely vessel(s) that are bleeding.

  8. If a patient is unstable: resuscitation comes first! As mentioned before, rarely will a patient bleed enough to have concurrent hemorrhagic shock along with hemoptysis. Reverse coagulopathy, provided blood & blood products, use pressor agents if/when indicated. For more on physiologically difficult intubations, check out our episode here!

  9. Intubation provides opportunities for intervention and further diagnosis but remember: intubating a patient with hemoptysis completely removes their cough reflex! When the airway is secured and aggressive suction / bronchoscopy can be achieved, you may be out of the woods (for a time). However, the induction/peri-intubation period when a patient is paralyzed without an airway is a VERY dangerous time and requires tremendous caution and focus. DO NOT take the decision to intubate lightly!!

  10. If a patient requires intubation, direct laryngoscopy (with a VL or DL blade) is the preferred option. Blood in the airway will quickly contaminate your field/view via the video scope.

  11. Suction, suction, suction! Prior to intubation, have two, functioning suction catheters / Yaunkers / etc. ready to go and within arms reach. Dr. Warren recommends having a trach-suction catheter at the bedside to provide even greater suction. We also recommend having bronchoscopy immediately available for use post-intubation / stabilization. If you have interventional pulmonology on-call, this may be the time to give them a shout!

  12. The Dual-Lumen Endotracheal Tube: To Place or Not To Place? Generally no. This sounds appealing, but placing these is technically challenging and cumbersome. Most individuals outside of cardiothoracic anesthesiologists do not have a lot of experience with these and thus, attempting to place on during a pressure-packed stressful situation is suboptimal. We recommend against it.

  13. So how should you intubate these patients? Initially, a standard tracheal intubation is reasonable. If you have a chest X-ray prior to intubation, Dr. Warren recommends we consider using the bronchoscope to guide the tube towards or away from the likely bleeding source.

  14. Intubating the affected side allows you to immediately perform interventions to temporize/tamponade/stop bleeding. Dr. Warren highlights the benefits of this approach from a therapeutic standpoint, but warns us that it is a more advanced technique and should only be done by a skilled operator / interventional pulmonologist.

  15. More commonly, if selective intubation is performed, the unaffected side should be intubated in order to protect that single-lung from “spill-over” therefore allowing for single-lung oxygenation/ventilation. If this is done, ensure the ventilator settings are appropriate for single lung ventilation and that definitive management is en-route. You can also consider leaning the patient with the bleeding side down to further minimize the potential for spill-over.

  16. Following successful intubation, there are different options for management. Endobronchial blockers (EBB) are an appealing option to provide tamponade and temporize a bleed while awaiting definitive management. One benefit to using an EBB is that in left-sided bleeds, rather than selectively intubating the right side and likely jailing/blocking the RUL, you can intubate the trachea and occlude the left lung via an EBB, allowing for full single-lung ventilation which is more easily tolerated. Check out this YouTube video (not ours) for more and this link that Dr. Warren highly recommends!

  17. If you are more comfortable with advanced bronchoscopy or an interventionist is available to support, Dr. Warren mentions that some clinicians may use a CRE balloon to occlude/interrogate the bleeding side as this can provide better visualization and more precise placement than an EBB. Interventionalists may also be able to support via cryotherapy, argon plasma coagulation (APC), or the use of a YAG laser in conjunction with rigid bronchoscopy - all in the appropriate clinical setting.

Ultimately, definitive therapy for massive hemoptysis is necessary. This is typically IR embolization of the culprit bronchial artery branch, although in certain cases cardiothoracic surgery may need to engage if IR or vascular surgery are unable to intervene endovascularly. These interventions, and so much more, are discussed in this awesome 2019 CHEST review of massive hemoptysis management.

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Nick Mark
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