• • Severe hemoptysis is a life-threatening medical emergency.
  
• • Careful systematic workup is needed to identify the origin and reason for hemoptysis.
  
• • The anesthesiologist should play an important role in identifying the severity and origin of hemoptysis, initiation first-aid management, and follow a systematic therapeutic plan according to the severity of hemoptysis.
  
• • The anesthesiologist should select the best option for securing airway and sealing the source of bleeding from lung.
  
• • There is no consensus on the best lung isolation tool in patients with hemoptysis, and it should depend upon the clinical scenario.

Hemoptysis may present as mild or as a life-threatening condition. Massive hemoptysis, a major medical emergency associated with a high mortality,¹ has been defined in the literature by several different criteria, ranging from 100 to 600 mL of blood over wide-ranging periods of time.^2,3 These variations in definition are impacted by the difficulty in quantifying the amount of blood expectorated, which may be overestimated by patients.³ In general, any hemoptysis that jeopardizes respiratory function should be considered a life-threatening medical emergency.¹

Case Presentation

A 22-year-old male sustained several stab wounds to the back which penetrated into the right chest. He presented to the emergency department agitated and confused with severe hemoptysis, tachycardia, tachypnoea, and dyspnea. Physical examination revealed cyanosis, signs of respiratory distress, and absent breath sounds on the right chest. The arterial oxygen saturation was 83%, with a nonrebreather mask supplying oxygen at 15 L/min. Hemoglobin concentration was 7.5 g/dL and lactic acid was 3.7 mmol/L. Point-of-care sonography and chest radiograph showed a right hemopneumothorax. Electrocardiogram and transthoracic echocardiography showed no abnormalities.

Case Management

A chest tube was inserted to the right chest and a total of 1.2 L of blood was drained. Lactated Ringer’s solution 2.0 L and 2 units of type-crossmatched packed red blood cells were administered and was followed with improved blood pressure and the level of consciousness. Chest radiography and computed tomography (CT) confirmed the presence of right hemopneumothorax. Cervical and abdominal CT scanning showed no abnormalities. The patient was brought to the operating room (OR) for emergency exploration via right posterolateral thoracotomy.

Problem A: How Can We Reduce Risk by Intraoperative Monitoring?

Routine monitors included five-lead electrocardiograph with ST segment analysis, processed electroencephalographic-based control the depth of anesthesia, and train-of-four stimulation of the ulnar nerve. Transcutaneous multifunction pads for monitoring, defibrillation, and pacing were connected to the chest wall. The radial artery was cannulated and connected to a fluid responsiveness monitoring system to guide hemodynamic parameters. An 8.0-F cordis was placed in the right internal jugular vein, and a urethral Foley’s catheter was placed.

Rapid sequence induction was considered, a left-side double-lumen tube (DLT) was placed, and the proper DLT position was confirmed using a flexible 4.0-mm bronchoscope in both supine and lateral decubitus positions. Bronchoscopic examination showed significant bleeding from the right lower lobe, and the presence of major trachea-bronchial injury was ruled out. Surgery consisted of right thoracotomy and repair of the right lower lobe bronchial injury. The patient was extubated at the end of the procedure and postoperative course were uneventful.

Cause of Hemoptysis

Several causes for hemoptysis are presented in Table 48.1.

Therapeutic Options³

1. 1. General Initial Management

• Caution should be exercised for the classic ABCDE approach for management of patients with life-threatening hemoptysis (Box 48.1).
  
• ABCDE Approach
  
• Airway: Maintain the patency of airway. Intubation with a single-lumen tube (SLT) is recommended until the origin of bleeding is localized. In patients with lateralized or localized persistent bleeding, immediate control of the airway may be achieved by insertion of a DLT to isolate and ventilate the lungs and prevent spillage of blood to the contralateral lung, separately, or by endobronchial tamponade with a bronchial blocker.^1,13
  
• Breathing: Supplementary oxygen should be provided to every patient with hemoptysis. Respiratory rate and oxygen saturation should be closely monitored, and the amount of the hemoptysis should be quantified.^1,3
  
• Circulation: Monitoring of vital signs (blood pressure, heart rate, and capillary refill time) and placement of a large caliber venous access for rapid fluid administration and, if necessary, blood transfusion should be considered to stabilize the hemodynamic status. The use of uncross-matched units of either type specific or group O packed red blood cells (PRBCs) can be used in emergency bleeding situations.^1,3
  
• Disability/Position: If the bleeding site is identified, the patient should be placed with the bleeding side down, to prevent blood contamination into the uninvolved lung. Chest physical therapy techniques must be avoided.^1,3
  
• Exposure: Bedside x-ray can be used to narrow down the origin of hemoptysis although it often inconclusive.

1. 2. Other Measures to be Considered in the Management of Hemoptysis Include³
   
   
   
   1. A. Administration of antitussives to control coughing, however, oversedation should be avoided owing to the fear of airway obstruction.⁵
      
   2. B. Empiric antibiotic treatment, useful in hemoptysis associated with respiratory infection and, in general, to prevent subsequent complications.
      

      Antifibrinolytics (e.g., aminocaproic acid, tranexamic acid [TA]).³ The clinical benefit of using TA has mixed results in the literature. Tscheikuna et al. enrolled 46 patients with hemoptysis completed the study. There were 21 in the TA group and 25 in the placebo group. The placebo group had a tendency not to have underlying lung disease and more patients who had a normal CXR. The benefit of TA in shortening the days of hemoptysis were not shown in this study.¹⁴ Some investigators demonstrated that TA is effective in shortening the duration and volume of hemoptysis with low risk of thromboembolic complications. Moen et al. performed an analysis of 13 publication that represented the best evidence to answer the clinical question. Main outcomes included bleeding time, bleeding volume, and occurrence of thromboembolic complications after start of treatment. Based on results from the metaanalysis, no difference in remission of bleeding within 1 week was found between the TA and placebo groups. However, overall bleeding time was significantly shorter for the TA group. The authors concluded that limited research on the use of TA for treatment of hemoptysis exists. Because etiology of hemoptysis, as well as length of treatment, dosage, and form of TA administration varied between the studies, strong recommendations are difficult to give. Current best evidence, however, indicates that TA may reduce both the duration and volume of bleeding, with low risk of short-term thromboembolic complications in patients with hemoptysis.¹⁵ Interestingly, inhaled TA (500 mg 3 times daily) can be used safely and effectively to control bleeding in patients with nonmassive hemoptysis.¹⁶

      
      
   3. C. Autologous plasma rich platelets have been shown to stop bleeding immediately in 14 out of 20 patients with massive hemoptysis for 7 days.¹⁷
      
   4. D. Desmopressin, a fast-acting blood-saving agent, can be used to control hemoptysis in various hereditary and acquired clotting disorders.¹⁸
   
   
2. 3. Specific Treatment
   

   A coordinated emergency team response is essential to guarantee the best chances of patient survival.⁷ A systematic approach for definitive treatment of the patients with or without life-threatening hemoptysis has been developed from the previous reviews,^2,3,5,19,20 as shown in Fig. 48.2. The main steps are as follows:

   
   
   
   
   1. A. Massive life-threatening hemoptysis:
      
      
      
      1. i. In patients with unstable hemodynamic status, initial general treatment measures are considered to stabilize the patient’s conditions. Immediate bronchoscopy should be performed in a well-equipped area (e.g., OR or ICU) to identify the cause and origin of the bleeding, secure the airway, administering topical measures to control bleeding (e.g., bronchial lavage, cryotherapy),^21,22 and applying topical hemostatic agents (e.g., cold saline³ or less effective epinephrine diluted at 1:20,000²³), sealants (e.g., Fibrinogen-thrombin [Tissucol], oxidized regenerated cellulose mesh [Surgicel] or silicone plugs [Watanabe spigot]),³ laser photocoagulation,²⁴ or argon plasma electrocoagulation.³ More definitive treatment options include angiographic embolization,^25,26 emergency surgery for lung resection,²⁷ or bronchial artery ligation surgery.²⁸ Extracorporeal membrane oxygenation (ECMO) could be considered as a rescue strategy in case of life-threatening aortobronchial fistula.²⁹
         
      2. ii. Patients with stable hemodynamic status should be subjected to either angiographic multidetector CT scanning or angiography to predict the value of bronchial artery embolization (Fig. 48.3). Reembolization or emergency surgery could have an important role in case of uncontrolled bleeding after embolization.
      
      
   2. B. Mild to moderate hemoptysis:
      
      
      
      1. i. Multidetector or volumetric high-resolution CT scanning should be considered as a diagnostic tool.
         
      2. ii. Early bronchoscopy within 48 hours after presentation should be considered if the origin of bleeding could not be identified. Bronchial lavage, cryotherapy, applying topical hemostatic agents or sealants, or selective bronchial blockage of the affected area should be considered in patients with active bleeding. Caution should be exercised in patients with no active bleeding during removal of remaining blood and examination should be postponed if the clot is adhered.

Airway Protection

Isolation of the Bleeding Lung/Lobar (see Chapter 16)

There is no consensus on the best method of lung isolation for patients with hemoptysis (Case Studies shown in Fig 48.4).

1. 1. Bronchial Blockers
   

   Bronchial blockers can be used for isolating the main bronchus or selective lobar bronchus blockade to allow control of the bleeding lung or lobe, respectively by tamponade. The bronchial blockers are usually available in 7.0 F or 9.0 F for adult patients who require tracheal intubation with a SLT with a minimum size of 7.5 or 8.0 mm inner diameter, respectively. That allows the insertion of the flexible bronchoscopes with a size of 3.8 to 4.0 mm outer diameter.³⁸ The use of video laryngoscopes allows effective suctioning of blood and direct visualization of tracheal intubation with the bronchial blocker before placement of the SLT. Bronchial blockers could be placed through tracheostomy tube in patients with tracheostomies.³⁹

   
   

   Bronchial blockers are more expensive than DLTs may take longer time to placement, and could be associated with more frequent dislodgement.^40,41 The use of bronchial blockers limits the effective suctioning of blood because of their narrow inner lumens. In addition, blood stagnation in the lung distal to the blocker’s inflated cuff has long-term side effects.⁴² However, if the patient is bleeding with the SLT in place and there is a concern regarding control of airways while converting to a DLT, it is best to use a bronchial blocker to tamponade the main bronchus of the bleeding side.

   
   

   There are several types of blockers as summarized subsequently and in Table 48.2.

   
   
   
   

   Table 48.2

   
   

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

   Author’s Recommended Choices for Selective Lung/Lobar Blockade Based on the Current Evidences Available

   Lung/Lobe	Double-Lumen Tube Side	Fuji Uniblocker Torque Control	Arndt Wired Tip	Cohen Deflecting Tip	EZ Blocker	Coopdech Angled Tip
   Right lung	Left or right
   Right upper lobe	Left
   Tracheal bronchus	Left
   Right middle lobe	Left or right
   Right lower lobe	Left or right
   Left lung	Left or right
   Left upper lobe	Left or right
   Left lower lobe	Left or right
   References	42	40,115	45,46	13,42	48,49	50–54

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