EMS calls; they are 5 minutes out
with a 50-year-old female patient in cardiac arrest with massive airway bleeding. She began coughing up blood and collapsed several minutes prior to EMS arrival. She is currently intubated with a 7.0 ETT, 3 doses of epinephrine have been administered, and CPR is ongoing; she has been alternating between
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What defines massive hemoptysis?
There is no consensus on the definition of “massive.” Many sources use a definition of 600cc of expectorated blood per hour, but proposed cutoffs run between 200 and 1000 mL/hr.  However, estimating blood volumes can be difficult and it may only take 100-400mL of blood in the airway to cause impaired gas exchange.[1,2] Because of this, some proposals call for inclusion of other clinical data including evidence of impaired gas exchange or hemodynamic derangements to define “massive.”
What is the likely etiology of this patient’s cardiovascular collapse?
Asphyxiation rather than exsanguination is the most likely cause of cardiovascular collapse in massive hemoptysis. 90% of cases of massive hemoptysis are caused by bleeding in the bronchial circulation, which is exposed to systemic pressures; bleeding in the low pressure pulmonary circulation accounts for only 5% of cases.
What is the likely etiology of the hemoptysis?
The list of possible causes of massive hemoptysis is extraordinarily large, and includes many rare conditions. The most common causes are bronchiectasis (often due to TB or cystic fibrosis), lung cancer, and pneumonia. TB is a common cause in endemic areas, but less common in the developed world. Other etiologies include infectious causes e.g., fungal infections, necrotizing pneumonia, and parasitic infections; alveolar hemorrhage; vascular disorders such as AVMs, PEs, or aneurysms; trauma; iatrogenic causes; and inflammatory conditions such as Wegner’s or Lupus.
What is the initial treatment for massive hemoptysis? What aspect of the treatment was non-ideal in this case?
In cases of life-threatening hemoptysis, control of the airway is the first priority. Intubation with an ETT 8.0 or greater is strongly preferred. Flexible bronchoscopes can be passed through a smaller tube, but rigid bronchoscopy requires larger tubes.[1,2]
Selective mainstem intubation is an option if the hemorrhage can be localized to one lung and if the bleeding is severe. Simply rotating the ET tube to the desired side after passage through the vocal cords and advancing until resistance is met has been shown in cadavers to be reasonably reliable in producing selective intubation of the desired mainstem.  Right main intubation is easier to accomplish, but will often will occlude the right upper lobe as well, hindering gas exchange. 
Double lumen tubes can also be used to isolate the bleeding side; they are often inserted with assistance of flexible bronchoscopy. They can be blindly inserted, but can also be blindly mis-inserted. If rigid bronchoscopy is available, keep in mind that the interior diameter of each lumen is too small to allow anything besides a pediatric bronchoscope to pass, limiting the ability to suction airway or stop bleeding. 
Pulses return and the airway is temporarily managed, what now?
Chest X-Ray or Chest CT. CXR should be obtained as soon as possible, as it may help identify the side of bleeding (although 20%-46% of the time it won’t be helpful) and in some cases may help identify the cause of bleeding, e.g., if there is a visible mass or cavitary lesion. CT is superior to CXR in identifying site of bleeding and superior to bronchoscopy in identifying the etiology of the bleeding, but is only suitable for patients stable enough for transport out of the department. CT may also help plan for possible angiographic intervention, and CT with contrast can help identify AVMs or aneurysms.
If a side of bleeding can be successfully identified, patients should be placed in the bleeding-side-down recumbent position although evidence supporting this is sparse.[1,7]
- Initial interventions
Bronchoscopy is considered by many sources to be the first line intervention in actively bleeding/critical patients, since it is therapeutic as well as diagnostic. Treatment options with the bronchoscope include cold saline lavage, application of hemostatic agents or vasoconstrictive agents, laser photocagulation or electrical cautery (laser and electric are only useful if a bleeding site is clearly identified), or mechanical devices such as balloons to tamponade bleeding or isolate the bleeding lung or lung segment.  Parenteral tranexamic acid can be considered, but with bronchoscopy it can also be applied directly to a bleeding site. Fungal infections sometimes require local instillation of antifungal agents. 
Flexible bronchoscopy can reach more distal airways, but the rigid bronchoscope has more options for intervention and greater ability to suction blood and clots. If rigid bronchoscopy is not available, flexible bronchoscopy can be used to some suctioning and may allow selective intubation with visualization, rather than the blind technique described above. 
The initial priority is resuscitation, and blood type should be obtained with subsequent cross matching of several units of blood (one source recommends an empiric 6 units).  Other labs should be obtained including coagulation studies, CMP (uremia can cause platelet dysfunction and may require platelet transfusion), CBC, possibly sputum, and a UA (blood may suggest Goodpasture’s).
- Medical Interventions
Don’t forget to reverse any coagulopathy and to consider the need for transfusions with either cross-matched or O-positive (or O-negative for childbearing age females) blood. [2,7] Cough-suppressants have been proposed, but there is no evidence supporting their use, and there is a theoretical risk of retaining blood in the airways . As mentioned, parenteral tranexamic acid can be considered. [2,8]
- Angiography and Surgery
Surgical intervention is always a consideration, but there is limited data about outcome compared with non-surgical treatment. The most recent consensus is that embolization should be attempted first, since angiographic intervention is successful in stopping bleeding between 64 and 100% of cases (though rebleeding can occur). 
A primary surgical approach can be considered in cases of an aspergilloma, pulmonary artery bleeding in the setting of a tumor, multiple or complex AVMs, or necrotizing lung infections, since these often require surgical resection. It is also an option in patients too unstable to go angiography.  Patients with very poor baseline lung function may not be able to tolerate loss of any pulmonary segments, a major concern for surgical planning. 
Unfortunately, this patient never did regain a pulse and remained in PEA or asystole throughout the attempted resuscitation. CPR had been ongoing in the field for approximately 30 minutes prior to arrival; bag valve mask ventilation and subsequently ventilation after intubation had been difficult. CPR was discontinued and the patient was declared dead.
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3. Wong BK. Hemoptysis – Massive or not. Proceedings of UCLA Healthcare. 2014;(18).
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5. Bair AE, Doherty MJ, Harper R, Albertson TE. An evaluation of a blind rotational technique for selective mainstem intubation. Acad Emerg Med. 2004;11(10):1105-7. PMID: 15466157
6. Jean-vivien S, Clément D, Jean-pierre T, Yves A. Double-lumen endobronchial tube and alternatives in massive hemoptysis: How do you want to save lives?. J Emerg Trauma Shock. 2011;4(3):438. PMCID: 3162725
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8. Moen CA, Burrell A, Dunning J. Does tranexamic acid stop haemoptysis?. Interact Cardiovasc Thorac Surg. 2013;17(6):991-4. PMID: 23966576