#EMConf: Massive Hemoptysis Part II

Refer here for part I of this case


  • Airway - this patient asphyxiated and lost pulses for that reason
    • Suctioning is key. Refer here.
    • Direct laryngoscopy is preferred over video laryngoscopy in large volume reguritation. 
    • Place an 8-0 ETT to facilitate bronchoscopy. 
    • Mainstem the tube if possible
    • Place the patient with the bleeding lung down to avoid soiling of the normal lung.
    • Should I place a double lumen ETT?
      • Balloon in bronchus and balloon in trachea which helps ventilate both lungs while simultaneously preventing soiling of good lung. 
      • 50% are misplaced even when in the OR by thoracic anesthesiologists and you can't perform bronchoscopy through them.
  • Mechanical Ventilation: Manage the vent like ARDS (kind of) as this is a gas exchange and shunt problem. 
    • There are no universal vent management strategies in massive hemoptysis. 
    • Recruitment maneuvers were attempted three times.
    • BVM with PEEP valve was used when patient's pulse oximetry dropped to ~ 50%
    • Transitioned from PRVC to Pressure Control 
    • Paralytic was used
    • Epoprostenol was started
    • ARDS Maneuvers for Refractory Hypoxemia that are not applicable to this patient:
      • Proning - can soil good lung and difficult logistically in the Emergency Room
      • APRV - not appropriate for this patient because need spontaneous breathing (this patient is paralyzed) and patients with hypercapnic respiratory failure/respiratory acidosis (as in this case) don't do well with this mode. 
    • ECMO was discussed but patient did not fail primary management (Bronchoscopy v. Embolization)