#EMConf: Massive Hemoptysis Part II
Thu, 01/24/2019 - 6:00am
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)