Title: Pearls for the Patient with Massive Hemoptysis<br/>Author: Caleb Chan<br/><a href='http://umem.org/profiles/alumni/1583/'>[Click to email author]</a><hr/><p>
<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;"><span font-size:="" helvetica="">-If the patient is able to maintain mentation/airway/SpO2/hemodynamics and cough up blood, intubation is not immediately necessary </span></span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;"><span font-size:="" helvetica="">an ETT will actually reduce the diameter of the airway and can impede clearance and precipitate respiratory failure</span></span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;"><span font-size:="" helvetica="">-If you do intubate, intubate with the largest ETT possibly to faciliate bronchoscopic interventions and clearance of blood</span></span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;"><span font-size:="" helvetica="">Men: 8.5 or above; Women: 8.0 or above</span></span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">-The CT scan that typically needs to be ordered is a CTA (<u><strong>not</strong></u> CTPA) with IV con</span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">90% of life-threatening hemoptysis from the bronchial arteries</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">-See if you can find prior/recent imaging in the immediate setting (e.g. pre-existing mass/cavitation on R/L/upper/lower lobes) </span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">having a level of suspicion for location/lateralization is helpful for the performing bronchoscopist to allow them to empirically occlude a location with an endobronchial blocker in a crashing hypoxemic patient if visualization is difficult 2/2 blood</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">-Get these meds ready before the bronchoscopist gets to the bedside to expedite care: </span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">iced/cold saline, thrombin, code-dose epi (which will be diluted)</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">there is also some (not great) data for <u>intravenous</u> TXA and improved outcomes</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">-If the pt's vent suddenly has new high peak pressures or decreased volumes after placement of endobronchial blocker, be concerned that the blocker has migrated</span></span></p>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">this can happen even with 1 cm movement of the ETT or blocker, or extension of the patient's neck</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">know where the ETT is secured as well as the endobronchial blocker (analagous to locking of a transvenous pacer)</span></span></li>
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<span style="font-size:14px;"><span style="font-family:arial,helvetica,sans-serif;">pts with endobronchial blockers should also be on continuous neuromuscular blockade</span></span></li>
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<fieldset><legend>References</legend>
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Charya AV, Holden VK, Pickering EM. Management of life-threatening hemoptysis in the ICU. J Thorac Dis. 2021;13(8):5139-5158.</p>
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