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EMedHome's Clinical Pearl

Airway Control Comes First in Massive Hemoptysis

doi: 10.1097/01.EEM.0000651012.19700.08
    hemoptysis. hemoptysis


    Massive hemoptysis is a true emergency with high mortality that presents management challenges. A small amount of blood can rapidly flood the airway, impairing oxygenation and ventilation and leading to asphyxia. Early control of the patient's airway is of paramount importance. (Crit Care Med. 2000;28[5]:1642.) Emergency physicians should be familiar with several concepts before a patient with massive hemoptysis arrives at the ED to make a stressful situation easier (Can Respir J. 2017;2017:1565030; Anesthesiology. 2006;104[2]:261):

    • If the side of bleeding is known, immediately move the patient into the decubitus position with the bleeding side down to prevent the hemorrhage from flooding into other regions of the lung.
    • Intubation with a larger diameter (>8.5 mm) endotracheal tube (ETT) when possible enables passing therapeutic flexible bronchoscopes with large working channels that allow extraction of obstructing blood clots and placing bronchial blockers.
    • An inflatable bronchial blocker or Fogarty balloon can be inserted coaxially through an ETT or parallel to the ETT to prevent spilling blood to the contralateral side.
    • In the absence of balloon occlusion, selective intubation into the left- or right-sided mainstem with an ETT can isolate the lung from the hemorrhage on the contralateral side.

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