Airway Management An Introduction and Overview

Report
Airway Management:
An Introduction and Overview
&
Massive Hemoptysis
Division of Critical Care Medicine
University of Alberta
Airway Management
Outline
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Overview
Normal airway
Difficult intubation
Structured approach to airway
management
Causes of failed intubation
Overview of the Airway
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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
Indications for Intubation
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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:

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
The Normal Airway
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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
The Normal Airway
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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
The Normal Airway
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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
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
Signs Indicative of a Difficult
Intubation
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Neck Abnormalities
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Thoracoabdominal abnormalities
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Short and thick
Decreased range of motion (arthritis, spondylitis, disk
disease)
Fracture (subluxation)
Trauma
Kyphoscoliosis
Prominent chest or large breasts
Morbid obesity
Term or near term pregnancy
Age 50 – 59
Male gender
Difficult Intubation - History
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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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Nose:
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Pierre Robin
Treacher Collins
Klippel – Feil
Apert’s syndrome
Fetal Alcohol syndrome
Acromegaly
For nasal intubation
Patency
Pierre Robin
Treacher Collins
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
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:

Size and mobility
Mallampati Classification
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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
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Difficult to Intubate
Mallampati Classification
Structured Approach to Airway
Management
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MOUTHS
Component
Description
Assessment Activities
Mandible
Length and subluxation
Measure hyomental distance and
anterior displacement of mandible
Opening
Base, symmetry, range
Assess and measure mouth opening
in centimetres
Uvula
Visibility
Assess pharyngeal structures and
classify
Teeth
Dentition
Assess for presence of loose teeth
and dental appliances
Head
Flexion, extension, rotation
of head/neck and cervical
spine
Assess all ranges and movement
Silhouette
Upper body abnormalities,
both anterior and posterior
Identify potential impact on control
of airway of large breasts, buffalo
hump, kyphosis, etc.
Bag/Valve/Mask Ventilation
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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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Two of these predictors of DMV
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Beard
BMI > 26
Edentulous
Age > 55 years of age
History of snoring (obstruction)
Sensitivity and specificity > 70%
DMV
Difficult Intubation in 30% of cases
Intubation Technique
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Preparation:
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Equipment Check
 100% oxygen at high flows (> 10 Lpm) during
bask/mask ventilation
 Suction apparatus
 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
Pre - oxygenation
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Traditional:
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Rapid
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3 minutes of tidal volume breathing at 5 ml/kg 100%
O2
8 deep breaths within 60 seconds at 10 L/min
Always ensure pulse oximetry on patient
Positioning
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Optimal Position – “sniffing position”
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Flexion of the neck and extension of the antlantooccipital joint
Mandible and Floor of Mouth
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Optimal position:
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flexing neck and extending the atlantooccipital
joint
Positioning
Positioning
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
Visualization
Visualization
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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
Visualization
Visualization
Laryngoscopy Grade
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Grade
Grade
Grade
Grade
I - 99%
II - 1%
III - 1/2000
IV - 1/ 10,000
Insertion
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Insert cuff to ~ 3 cm beyond cords
Tendency to advance cuff too far
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Right mainstem intubation
Cuff Inflation
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Inflate to 20 cm H2O
Listen for leak at patients mouth
Over inflation can lead to ischemia of trachea
Confirmation ETT Position
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Continuous CO2 monitoring or capnometry
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Gold standard
Must have at least 3 continuous readings
without declining CO2
False Negative Results
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Tube in Trachea, Capnogram Suggests Tube in
Esophagus
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Concurrent PEEP with ETT cuff leak
Severe Airway obstruction
Low Cardiac Output
Severe hypotension
Pulmonary embolus
Advanced pulmonary disease
False Positive Results
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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
False Positive Results
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
Airway Maneuvers
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BURP – Improves visualization of airway
1.
2.
3.
4.
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)
Causes of Failed Intubation
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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
Summary
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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:
1.
Ventilatory Support
2.
Decreased GCS
3.
Protection of Airway
4.
Ensuring Airway patency
5.
Anesthesia and surgery
6.
Suctioning and Pulmonary Toilet
7.
Hypoxic and Hypercarbic respiratory Failure
8.
Pulmonary lavage
Massive Hemoptysis
Massive Hemoptysis
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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
Localized Bleeding
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Infections
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Bronchitis
Bacterial Pneumonia
 Streptococcus and
Klebsiella
Tuberculosis
Fungal Infections
 Aspergillus
 Candida
Bronchiectasis
Lung Abscess
Leptospirosis
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Tumors
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Bronchogenic
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Necrotizing
parenchymal cancer
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Squamous
Adenocarcinomas
Bronchial adenoma
Cardiovascular
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Mitral Stenosis
Localized Bleeding
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Pulmonary
Vascular Problems
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Pulmonary AV
malformations
 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
Sarcoidosis (cavitary
lesions with
mycetoma)
Ankylosing spondylitis
Diffuse Bleeding
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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
Hemosiderosis
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Blood dyscrasias
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Thrombotic thrombocytopenic
purpura
Hemophilia
Leukemia
Thrombocytopenia
Uremia
Antiphospholipid antibody
syndrome
Pulmonary – Renal Syndrome
 Goodpasture syndrome
 Wegener granulomatosis
 Pauci-immune vasculitis
Diffuse Bleeding
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Vasculitis
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Pulmonary capillaritis
 With or without connective tissue disease
Polyarteritis
Churg-Strauss syndrome
Henoch-Schonlein Purpura
Necrotizing vasculitis
Connective Tissue diseases
 Systemic lupus erythematosus
 Rheumatoid arthritis
 Mixed connective tissue disease
 Scleroderma (rare)
Key Major Etiologies
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Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Other Infectious Causes
Pathophysiology
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Bronchial circulation
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High (systemic) pressure circulation
Drains into the right atrium (extrapulmonary bronchi)
Also drains into pulmonary veins (intrapulmonary
bronchi)
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
Clinical Findings
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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
Differential Diagnosis
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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.
Laboratory Tests
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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
Imaging Studies
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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
Stabilization
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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.
Treatment
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General Measures:
1.
2.
3.
4.
5.
6.
Place bleeding lung down to prevent aspiration into
good lung
Supplemental oxygen
Avoid Sedation
Correct coagulopathy and thrombocytopenia
Consult pulmonary, critical care, and thoracic
surgery
Consider early involvement of anesthesia and
interventional radiology
Primary Goal is Airway Control
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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.
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.
Bronchoscopic Interventions
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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
Unilateral Lung Ventilation
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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:


Occlusion of the anterior spinal artery with paraplegia.
Embolic infarction of distal organs.
Early Surgical Treatment



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.
Inability to localize bleeding site.
Diffuse lung disease (relative) eg. CF.
Mortality is higher if bleeding is acute
Late Surgical Treatment


Indicated for definitive treatment of
underlying lesion, once bleeding subsided.
Indications:



Mycetoma
Resectable carcinoma
Localized bronchiectasis
Prognosis

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.
Conclusion


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.

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