An Introduction and Overview
&
Massive Hemoptysis
Division of Critical Care Medicine
University of Alberta

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Overview
Normal airway
Difficult intubation
Structured approach to airway management
Causes of failed intubation

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600 patients die per year from complications related to airway management
3 mechanisms of injury:
1.
2.
3.
Esophageal intubation
Failure to ventilate
Difficult Intubation
98% of Difficult Intubations may be anticipated by performing a thorough evaluation of the airway in advance

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Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage

Endotracheal Intubation Depends
Upon Manipulation of:
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Cervical spine
Atlanto-occipital Joint
Mandible
Oral soft tissues
Neck hyoid bone
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Additionally:
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Dentition
Pathology - Acquired and
Congenital

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History of one or more easy intubations w/o sequelae
Normal appearing face with regular features
Normal clear voice
Absence of scars, burns, swelling, infections, tumour, or hematoma
No history of radiation of the head or neck
Ability to lie supine asymptomatically; no history of snoring or sleep apnea

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Patent nares
Ability to open mouth widely with TMJ rotation and subluxation (3 – 4 cm or two finger breaths)
Mallampati Class I
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Patient sitting straight up, opening mouth as wide as possible, with protruding tongue; the uvula, posterior pharyngeal wall, entire tonsillar pillars, and fauces can be seen
At least 6 cm (3 finger breaths) from tip of mandible to thyroid notch with neck extension
At least 9 cm from symphysis of mandible to mandible angle

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Slender supple neck w/o masses; full range of neck motion
Larynx moveable with swallowing and manually moveable laterally (about 1.5 cm each side)
Slender to moderate body build
Ability to extend atlanto-occipital joint
(normal extension is 35 ° )

Risk Factors For Difficult
Intubation
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El-Canouri et al. - prospective study of 10, 507 patients demonstrating difficult intubation with objective airway risk criteria
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Mouth opening < 4 cm
Thyromental distance < 6 cm
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Mallampati grade 3 or greater
Neck movement < 80%
Inability to advance mandible (prognathism)
Body weight > 110 kg
Positive history of difficult intubation

Signs Indicative of a Difficult
Intubation
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Trauma, deformity: burns, radiation therapy, infection, swelling, hematoma of face, mouth, larynx, neck
Stridor or air hunger
Intolerance in the supine position
Hoarseness or abnormal voice
Mandibular abnormality
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Decreased mobility or inability to open the mouth at least 3 finger breaths
Micrognathia, receding chin
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Treacher Collins, Peirre Robin, other syndromes
Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid notch with neck in full extension
< 9 cm from the angle of the jaw to symphysis
Increased anterior or posterior mandibular length

Signs Indicative of a Difficult
Intubation
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Laryngeal Abnormalities
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Fixation of larynx to other structures of neck, hyoid, or floor of mouth.
Macroglossia
Deep, narrow, high arched oropharynx
Protruding teeth
Mallampati Class 3 and 4

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Signs Indicative of a Difficult
Intubation
Neck Abnormalities
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Short and thick
Decreased range of motion (arthritis, spondylitis, disk disease)
Fracture (subluxation)
Trauma
Thoracoabdominal abnormalities
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Kyphoscoliosis
Prominent chest or large breasts
Morbid obesity
Term or near term pregnancy
Age 50 – 59
Male gender

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Previous Intubations
Dental problems (bridges, caps, dentures, loose teeth)
Respiratory Disease (sleep apnea, smoking, sputum, wheeze)
Arthritis (TMJ disease, ankylosing spondylitis, rheumatoid arthritis)
Clotting abnormalities (before nasal intubation)
Congenital abnormalities
Type I DM
NPO status

Difficult Intubation - Diabetes
Mellitus
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Difficult intubation 10 x higher in long term diabetics
Limited joint mobility in 30 – 40 %
Prayer sign
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Unable to straighten the interpharyngeal joints of the fourth and fifth fingers
Palm Print
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100% sensitive of difficult airway

Difficult Intubation - Physical Exam
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General:
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LOC, facies and body habitus, presence or absence of cyanosis, posture, pregnancy
Facies:
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Abnormal facial features
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Pierre Robin
Treacher Collins
Klippel – Feil
Apert’s syndrome
Fetal Alcohol syndrome
Acromegaly
Nose:
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For nasal intubation
Patency

Difficult Intubation - Physical Exam
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TMJ Joint – articulation and movement between the mandible and cranium
Diseases:
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Rheumatoid arthritis
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Ankylosing spondylitis
Psoriatic arthritis
Degenerative join disease
Movements: rotational and advancement of condylar head
Normal opening of mouth 5 – 6 cm

Difficult Intubation - Physical Exam
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Oral Cavity
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Foreign bodies
Teeth:
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Long protruding teeth can restrict access
Dental damage 25% of all anesthesia litigations
Loose teeth can aspirate
Edentulous state
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Rarely associated with difficulty visualizing airway
Tongue:
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Size and mobility

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Class I: soft palate, tonsillar fauces, tonsillar pillars, and uvuala visualized
Class II: soft palate, tonsillar fauces, and uvula visualized
Class III: soft palate and base of uvula visualized
Class IV: soft palate not visualized
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Class III and IV Difficult to Intubate

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Structured Approach to Airway
Management
MOUTHS
Component Description
Mandible Length and subluxation
Opening Base, symmetry, range
Uvula
Teeth
Visibility
Dentition
Assessment Activities
Measure hyomental distance and anterior displacement of mandible
Assess and measure mouth opening in centimetres
Assess pharyngeal structures and classify
Assess for presence of loose teeth and dental appliances
Assess all ranges and movement Head Flexion, extension, rotation of head/neck and cervical spine
Silhouette Upper body abnormalities, both anterior and posterior
Identify potential impact on control of airway of large breasts, buffalo hump, kyphosis, etc.

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Always need to anticipate difficult mask ventilation
Langeron et al. 1502 patients reported a 5% incidence of difficult mask ventilation
5 independent risk factors of difficult mask ventilation:
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Beard
BMI > 26
Edentulous
Age > 55 years of age
History of snoring (obstruction)
Two of these predictors of DMV
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Sensitivity and specificity > 70%
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DMV Difficult Intubation in 30% of cases

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Preparation:
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Equipment Check
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100% oxygen at high flows (> 10 Lpm) during
 bask/mask ventilation
Suction apparatus
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Intubation tray
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Two laryngoscopic handles and blades
Airways
ET tubes
Needles and syringes
Stylet
KY Jelly
Suction Yankauer
Magill Forceps
LMA’s

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Traditional:
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3 minutes of tidal volume breathing at 5 ml/kg 100%
O
2
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Rapid
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8 deep breaths within 60 seconds at 10 L/min
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Always ensure pulse oximetry on patient

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Optimal Position – “sniffing position”
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Flexion of the neck and extension of the antlantooccipital joint

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Optimal position:
 flexing neck and extending the atlantooccipital joint

Factors that Interfere with
Alignment
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Large teeth or tethered tongue
Short mandible
Protruding upper incisors
Pathology in floor of mouth
Reduced size of intra and sub mandibular space
Practical Note: Thyromental distance 6 cm or 3 finger breaths should show
Normal mandible

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Insert blade into mouth
Sweep to right side and displace tongue to the left
Advance the blade until it lies in the valeculla and then pull it forward and upward using firm steady pressure without rotating the wrist
Avoid leaning on upper teeth
May need to place pressure on cricoid to bring cords into view

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Grade I - 99%
Grade II - 1%
Grade III - 1/2000
Grade IV - 1/ 10,000

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Insert cuff to ~ 3 cm beyond cords
Tendency to advance cuff too far
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Right mainstem intubation
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Cuff Inflation
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Inflate to 20 cm H
2
O
Listen for leak at patients mouth
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Over inflation can lead to ischemia of trachea

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Continuous CO
2
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Gold standard monitoring or capnometry
Must have at least 3 continuous readings without declining CO
2

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Tube in Trachea, Capnogram Suggests Tube in
Esophagus
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Concurrent PEEP with ETT cuff leak
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Severe Airway obstruction
Low Cardiac Output
Severe hypotension
Pulmonary embolus
Advanced pulmonary disease

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Tube NOT in trachea, capnogram suggests tube in trachea
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Bag/valve/mask ventilation prior to intubation
Antacids in stomach
Recent ingestion of carbonated beverages
Tube in pharynx

Other Methods to Determine
Placement of ETT tube
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Auscultation
Visualization of tube through cords
Fiberoptic bronchoscopy
Pulse oximetry not improving or worsening
Movement of the chest wall
Condensation in ET tube
Negative Pressure Test
CXR

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BURP – Improves visualization of airway
Posterior pressure on the larynx against cervical vertebrae (Backward)
Superior pressure on the larynx as far as possible
(Upward)
Lateral pressure on the larynx to the right (Right)
With pressure (Pressure)

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Poor positioning of the head
Tongue in the way
Pivoting laryngoscope against upper teeth
Rushing
Being overly cautious
Inadequate sedation
Inappropriate equipment
Unskilled laryngoscopist

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600 patients die per year from complications related to airway management
3 mechanisms of injury:
1.
2.
3.
Esophageal intubation
Failure to ventilate
Difficult Intubation
Indication for intubation:
Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage

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More than 300 to 600 ml of blood in 12 to
24 hours.
Difficult to assess the actual amount.
Life threatening bleeding into the lung can occur without actual hemoptysis.

Causes of Hemoptysis and
Pulmonary Hemorrhage
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Localized bleeding
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Diffuse Bleeding

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Infections
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Bronchitis
Bacterial Pneumonia
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Streptococcus and
Klebsiella
Tuberculosis
Fungal Infections
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Aspergillus
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Candida
Bronchiectasis
Lung Abscess
Leptospirosis
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Tumors
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Bronchogenic
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Squamous
Necrotizing parenchymal cancer
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Adenocarcinomas
Bronchial adenoma
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Cardiovascular
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Mitral Stenosis

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Pulmonary
Vascular Problems
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Pulmonary AV malformations
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Rendu-Osler-Weber
Syndrome
Pulmonary embolism with infarction
Behcet syndrome
Pulmonary artery catheterization with pulmonary artery rupture
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Trauma
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Others
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Broncholithiasis
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Sarcoidosis (cavitary lesions with mycetoma)
Ankylosing spondylitis

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Drug and chemical
Induced
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Anticoagulants
D-penicillamine (seen with treatment of Wilson’s disease)
Trimellitic anhydride
(manufacturing of plastics, paint, epoxy resins)
Cocaine
Propylthiouracil
Amiodarone
Phenytoin
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Hemosiderosis
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Blood dyscrasias
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Thrombotic thrombocytopenic purpura
Hemophilia
Leukemia
Thrombocytopenia
Uremia
Antiphospholipid antibody syndrome
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Pulmonary – Renal Syndrome
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Goodpasture syndrome
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Wegener granulomatosis
Pauci-immune vasculitis

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Vasculitis
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Pulmonary capillaritis
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With or without connective tissue disease
Polyarteritis
Churg-Strauss syndrome
Henoch-Schonlein Purpura
Necrotizing vasculitis
Connective Tissue diseases
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Systemic lupus erythematosus
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Rheumatoid arthritis
Mixed connective tissue disease
Scleroderma (rare)

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Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Other Infectious Causes

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Bronchial circulation
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High (systemic) pressure circulation
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Drains into the right atrium (extrapulmonary bronchi)
Also drains into pulmonary veins (intrapulmonary bronchi)
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Anterior spinal artery may originate from bronchial artery (5% of cases)
Pulmonary circulation
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Low-pressure circulation
Multiple anastomoses exist between bronchial and pulmonary circulations

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Hemoptysis, Dyspnea, Cough, Anxiety
Fever, weight loss
Smoking and Travel history
Bloody sputum
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Frothy blood – sputum mixture
Bright red
Alkaline
Tachypnea, respiratory distress
Localized wheezing, rales, poor dentition
Digital clubbing
Hematuria

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Upper GI Bleeding
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Dark blood
Food particles
Acid pH
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Consider endoscopy
Upper airway bleeding
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Examine mouth, nose, and pharynx.

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No specific tests
CBC, diff, INR, PTT, platelet count
Electrolytes, BUN, Cr
Sputum culture and AFB
Urinalysis
ECG
ABG’s
Type and Screen

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Chest X-ray
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Normal suggests endobronchial or extrapulmonary source.
Potentially misleading
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Aspiration from distant source
Chronic changes unrelated to acute event
CT scan
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Useful in stable patients
Can detect bronchiectasis

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Ensure adequate ventilation and perfusion.
Most common cause of death is asphyxia.
Place patient in Trendelenburg position to facilitate drainage.
Lateral decub – Bleeding side down
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Prevent contamination of good lung.

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General Measures:
Place bleeding lung down to prevent aspiration into good lung
Supplemental oxygen
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Avoid Sedation
Correct coagulopathy and thrombocytopenia
Consult pulmonary, critical care, and thoracic surgery
Consider early involvement of anesthesia and interventional radiology

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Asphyxiation, not blood loss, is the cause of death.
Only stable patients with ability to protect and clear their own airway should be managed without intubation.
Intubation:
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Performed by experienced personnel.
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Large bore tube for bronchoscopy and suctioning.
Consider bronchial blocker or double lumen tube if bleeding site is known.

Secondary Goal is Localization of
Bleeding
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Bronchoscopy required.
Intubate prior to bronchoscopy.
Rigid bronchoscopy
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May facilitate better suctioning.
Inability to visualize beyond main stem bronchi and need thoracic surgeon.

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Bronchial blocker or Fogarty balloon catheter to occlude bleeding lung, lobe, or segment.
Topical coagulants:
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Fibrin or fibrinogen-thrombin solution.
Topical transexamic acid
Consider Nd:YAG laser coagulation, electrocautery, or argon plasma coagulation.
Lavaged iced saline
Topical epinephrine

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Single lumen tube advanced into main stem bronchus.
Double lumen tube:
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Protects non-bleeding lung.
Use left sided tube to prevent occlusion of Right upper lobe.
May be difficult to position.
Individual lumens too small for standard bronchoscope.
Airway obstruction frequent problem.
Displacement can lead to sudden asphyxiation.
Patient should be therapeutically paralyzed and not moved.

Bronchial Arteriography and
Embolization
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Favored initial approach if facilities and expertise available.
High success rate: approximately 90% when a bleeding vessel is identified.
Recurrence rate: 10 – 27%
10% of patients bleed from the pulmonary circulation
(TB or mycetoma).
Serious complications:
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Occlusion of the anterior spinal artery with paraplegia.
Embolic infarction of distal organs.

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Offers definitive treatment.
Indicated for lateralized massive life-threatening hemoptysis, or failure or recurrence after other interventions.
Contraindications:
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Poor baseline respiratory function.
Inoperable lung carcinoma.
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Inability to localize bleeding site.
Diffuse lung disease (relative) eg. CF.
Mortality is higher if bleeding is acute

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Indicated for definitive treatment of underlying lesion, once bleeding subsided.
Indications:
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Mycetoma
Resectable carcinoma
Localized bronchiectasis

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Factors likely affecting outcome
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Etiology of hemoptysis
Underlying co-morbid illnesses
Surgical vs. medical treatment
Mortality
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Medical mortality: 17 – 85%
Estimated early surgical mortality: 0 – 50%
Most case series reports preceded the development of angiographic embolization.

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More than 300 to 600 ml of blood in 12 to 24 hours.
Major causes:
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Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Primary goal is airway control followed by bleeding localization.