A systematic approach to the management of massive hemoptysis

Analysis of angiographic findings and short-term recurrence factors in patients presenting with hemoptysis

OBJECTIVES

The abnormal anatomical alterations of blood vessels during DSA angiography in patients with hematological disorders were retrospectively examined, and the influencing factors of short-term (≤ 6 months) recurrent hemoptysis were statistically analyzed, and the consistency between admission diagnosis and intraoperative diagnosis was evaluated.

METHODS

The intraoperative angiography data of patients who underwent selective bronchial artery embolization for hemoptysis in our hospital from January 2022 to December 2022 were reviewed. They were divided into the observation group and the control group based on whether there was recurrent hemoptysis. The Logistic regression model and forest map were employed to analyze the factors influencing the recurrence rate.

RESULTS

A total of 104 patients were encompassed in this study (12 cases of tuberculosis, 35 cases of infection, 4 cases of lung cancer, 8 cases of bronchiectasis, 22 cases of arteriovenous fistula, 16 cases of aneurysm, and 7 cases of pulmonary hypertension). The coincidence rate of preoperative and intraoperative diagnoses was 73.1%. Pulmonary arteriovenous fistula and aneurysm were the predominant types of diseases that were misdiagnosed. The short-term recurrence rate was 16.3%, mainly attributed to the reopening of responsible vessels related to embolization, angiography leakage, and leaky embolization of specific types of vessels. The recurrence rate of only patients with arteriovenous fistula and aneurysm accounted for 47% of the total recurrence rate. The right bronchial artery, right internal thoracic artery, right thyroid neck trunk, and age were the independent factors influencing the recurrence of hemoptysis (p < 0.05).

CONCLUSIONS

The main reason for angiographic leakage and embolization leakage in cases of hemoptysis is the lack of understanding of the anatomic variations of the vessels responsible. Careful examination of the specific types and locations of the vessels is the principal approach to reducing secondary operations.

Exacerbations of bronchiectasis

Bronchiectasis presents a significant challenge due to its rising prevalence, associated economic burden and clinical heterogeneity. This review synthesises contemporary understanding and literature of bronchiectasis exacerbations, addressing the transition from stable state to exacerbations, underlining the importance of early and precise recognition, rigorous severity assessment, prompt treatment, and prevention measures, as well as emphasising the need for strategies to assess and improve early and long-term patient outcomes. The review highlights the interplay between stable state phases and exacerbations in bronchiectasis, introducing the concept of "exogenous and endogenous changes in airways homeostasis" and the "adapted island model" with a particular focus on "frequent exacerbators", a group of patients associated with specific clinical characteristics and worse outcomes. The pathophysiology of exacerbations is explored through the lens of microbial and nonmicrobial triggers and the presence and the activity of comorbidities, elaborating on the impact of both exogenous insults, such as infections and pollution, and endogenous factors such as inflammatory endotypes. Finally, the review proposes a multidisciplinary approach to care, integrating advancements in precision medicine and biomarker research, paving the way for tailored treatments that challenge the traditional antibiotic paradigm.

Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management

Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.

Predictive Factors for Recurrent Hemoptysis after Bronchial Artery Embolization in Patients with Lung Cancer

PURPOSE

To identify clinical, radiological, and angiographic characteristics associated with recurrent hemoptysis after bronchial artery embolization (BAE) in patients with lung cancer and severe hemoptysis admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

A total of 144 consecutive patients with lung cancer who underwent BAE for life-threatening hemoptysis admitted in the ICU between 2014 and 2022 were retrospectively included. Demographics, laboratory values, clinical course, and radiological/angiographic features were compared between those with and without recurrent hemoptysis within 1 month after embolization.

RESULTS

Of the 144 patients (mean age, 60.2 years [SD ± 10.9]; females, 15.3%), 34.7% (50/144) experienced clinically relevant recurrent hemoptysis within 1 month; among them, 29 of 50 (58.0%) cases necessitated a second embolization. Massive hemoptysis was observed in 54.2%, with 16.7% receiving the vasopressin analog terlipressin. The mean volume of hemoptysis and simplified acute physiology score II (SAPS II) were 235 mL (SD ± 214.3) and 31.2 (SD ± 18.6), respectively. Computed tomography (CT) angiography revealed pulmonary artery (PA) injury (11.5%) and necrosis/cavitation (25.8%), and PA embolization was performed in 15.3% of cases. Technical success rate was 92%. SAPS II (P = .01), massive hemoptysis (P < .001), terlipressin use (P = .01), necrosis/cavitation (P = .01), and PA injury on CT angiography (P < .001) were associated with recurrent hemoptysis. Independent predictors on multivariate analysis were massive hemoptysis (P = .016) and PA injury on CT angiography (P = .001).

CONCLUSIONS

In patients with lung cancer and life-threatening hemoptysis treated by BAE, massive hemoptysis and PA injury identified on CT angiography are independent predictors of recurrent hemoptysis.

Massive Hemoptysis: An Unusual Complication of Left Atrial Appendage Occlusion Device in Two Patients

Left atrial appendage occlusion (LAAO) devices have emerged as a promising alternative for stroke prevention in non-valvular atrial fibrillation (NVAF) patients with contraindications to chronic anticoagulation therapy. The most common life-threatening procedural complications described in the literature include pericardial effusion, air embolism, and stroke. We here present a case report of two patients who experienced identical but rare post-procedural complications of pulmonary venous bleed, presenting as hemoptysis.

[Severe hemoptysis in the onco-hematology patient]

In France, even though it occurs only exceptionally in cases of hemopathy, severe hemoptysis in cancer is the leading cause of hemoptysis. Without adequate treatment, in-hospital mortality exceeds 60%, even reaching 100% at 6 months. The management of severe hemoptysis should be discussed with the oncologist. Aside from situations of threatening hemoptysis, in which bronchoscopy should be performed immediately, CT angiography is an essential means of localizing the bleeding and determining the causes and the vascular mechanisms involved. In more than 90% of cases, hemoptysis is linked to systemic bronchial or non-bronchial hypervascularization, whereas in fewer than 5%, it is associated with pulmonary arterial origin or, exceptionally, with damage to the alveolar-capillary barrier. The most severely ill patients must be treated in intensive care in centers equipped with interventional radiology, thoracic surgery and, ideally, with interventional bronchoscopy. Interventional radiology is the first-line symptomatic treatment. In over 80% of cases, bronchial arteriography with embolization allows immediate control. Emergency surgery should be avoided, as it is associated with significant mortality. Appropriate and adequate care reduces hospital mortality to 30%, enabling patients to benefit from the most recent, survival-prolonging treatments.

Massive Hemoptysis Simulation Curriculum Improves Performance

BACKGROUND

Massive hemoptysis is a rare, high-acuity presentation, which requires the integration of both cognitive and procedural skills. Simulation has been recommended to improve preparation for high-acuity, low-occurrence procedures; however, the effect of a simulation curriculum for massive hemoptysis management has never been investigated.

RESEARCH QUESTION

Does simulation for hemoptysis management improve competence?

STUDY DESIGN AND METHODS

Kern's six steps for medical education curriculum design were used iteratively to develop a simulation curriculum for the management of massive hemoptysis. Pulmonary and critical care medicine fellows from the University of Colorado participated in a local needs assessment and a massive hemoptysis simulation curriculum. Using a manikin-based massive hemoptysis simulator developed for this curriculum, the simulation session used repetitive practice, clinical variation, a range of difficulties, and directed feedback in a group practice setting. Time to management and performance were assessed for each management attempt; competence was assessed using a combined metric of management-related priorities and global entrustment.

RESULTS

During the needs assessment, fellows viewed massive hemoptysis management skills as important, while expressing their current confidence as low. Nineteen fellows participated in a 90-min case-based hemoptysis simulation during which each was exposed to five different cases and acted as the primary manager for two cases. There was significant improvement in performance from the first to final simulation attempts measured by time to successful management (14.24 vs 10.26 min, P = .0067) and entrustment (Global Assessment Scale, 1 [should not perform] to 5 [independent]; 4.11 vs 4.61; P = .015). Fellow self-assessed knowledge and confidence in hemoptysis management and endobronchial blocker placement improved significantly after the simulation.

INTERPRETATION

Hemoptysis simulation experience improves fellow confidence and skill for management of this high-acuity, low-occurrence presentation.

Massive hemoptysis in pregnancy due to invasive pulmonary aspergillosis with pulmonary tuberculosis co-infection

A 37-year-old woman, 25 weeks pregnant, experienced sudden massive hemoptysis. She had a background history of systemic lupus erythematosus (SLE) and past pulmonary tuberculosis (PTB). Emergency intubation was necessary, and bronchoscopy revealed blood pooling in both main bronchi, with active bleeding from the right upper lobe bronchus. Urgent computed tomography (CT) angiography of the bronchial artery identified a bleeding source and was successfully embolized. Antifungal and anti-tuberculous therapy was initiated based on bronchoalveolar lavage results. Despite initial improvement, hemoptysis recurred after the third week, leading to repeat embolization, followed by a caesarean section and right upper lobectomy. Both mother and baby survived, remaining well at a 6-week follow-up, emphasizing the complexities of managing recurrent hemoptysis during pregnancy and potential drug interactions.

A bench study on the prevention of lung-to-lung aspiration with double-lumen endobronchial tubes and bronchial blockers

Effective lung isolation prevents lung-to-lung aspiration during thoracotomy for the management of hemoptysis. Double-lumen endobronchial tubes (DLT) and bronchial blockers are commonly used for lung separation during thoracic surgery. In this study, the fluid-sealing characteristics of the endobronchial cuffs of three different commercially available DLTs (Broncho-Cath with a polyvinylchloride cuff, Broncho-Cath with a polyurethane cuff, and Human Broncho with a silicone cuff) and two different bronchial blockers (Arndt and Coopdech bronchial blockers) were evaluated using a benchtop model. The lateral decubitus position for the surgical management of bleeding from the right lung was simulated. The artificial tracheobronchial tree was placed horizontally, with the left bronchus in the dependent position and the right bronchus in the non-dependent position. In the DLT experiments, the tracheobronchial tree was intubated with left-sided DLTs, and the endobronchial cuff was inflated to maintain the intracuff pressure at 25 cmH2O. In the experiments with bronchial blockers, each bronchial blocker was inserted into the right bronchus, and the endobronchial cuff was inflated to seal the main bronchus. A fluid leakage test around the endobronchial cuff was performed using three different types of DLT (size 35, 37, and 41 Fr, each) and two different types of bronchial blockers (9 Fr). The 5 mL of colored water was poured into the right bronchus to simulate the blood flow from the operative side, and the times to the first and 100% leakage around the endobronchial cuff were recorded. Each bronchial blocker showed significantly less leakage over time than the other DLTs (P < 0.05). Fluid was not fully leaked around the cuffs for 24 h with either bronchial blocker. The times to first and 100% leakage were not significantly different among different types of DLTs. The times to first and 100% leakage did not also differ among the three different sizes of each type DLT. There was no significant difference in the time to first leakage around the endobronchial cuffs between Arndt and Coopdech bronchial blockers. Bronchial blockers provided a more effective seal against lung-to-lung aspiration than DLTs in the lateral decubitus position for thoracotomy in the benchtop model.

Case report: Total obstruction of the left main bronchus by a blood clot leads to pneumonectomy in a pregnant woman

Introduction and importance

Airway obstruction resulting from blood clot formation is observed across various clinical scenarios and is often preceded by hemoptysis. This condition can significantly compromise respiratory function, potentially leading to life-threatening ventilatory distress.

Case presentation

In this report, the authors present a case of acute airway obstruction associated with hemoptysis in an 18-week pregnant woman admitted to the emergency department for acute respiratory distress. Clinical and radiographic evidence strongly suggested the presence of an endobronchial blood clot causing focal airway obstruction. Diagnosis was confirmed through direct endoscopic evaluation.

Clinical discussion

Initial attempts to remove the obstructing clot from the airway involved lavage, aspiration, and forceps extraction by using a bronchoscope. In cases in which these measures proved ineffective, other management strategies include rigid bronchoscopy, embolization, and surgical resection.

Conclusion

Central airway obstruction is a critical condition caused by numerous factors such as tumours or blood clots. Treatment focuses on securing the airway, ensuring breathing, and using tools such as bronchoscopy for diagnosis and treatment. Surgery is considered a last resort when other methods are ineffective.

Acute Hemoptysis Caused by Eroding Spinal Fusion Hardware Into the Left Lower Lobe of the Lung

Hemoptysis can occur in rare cases as a late complication of anterior approach spinal rod surgery in the spine. Our patient presented with hemoptysis. At age 14, he underwent an anterior approach spine surgery for scoliosis. He underwent bronchoscopy, and a round serrated metal object was visible in the left lower lobe. Multiple attempts were unsuccessful in retrieving the metal object. A review of the imaging did not show obvious penetration of the spinal instrumentation into the lung; however, the metallic object was believed to be a round serrated metal object from the fusion spinal hardware. Due to low lung function and the risk of injuring the surrounding tissue, the patient was not deemed a candidate for lobectomy or removal of the hardware. Instead, the patient underwent a left bronchial arterial embolization (BAE) procedure, which successfully stopped the hemoptysis.

Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage

BACKGROUND

The current concept of bronchoscopy-associated massive airway hemorrhage is not accurate enough, and the amount of bleeding as the only evaluation criterion cannot comprehensively evaluate magnitude of the effects and the severity.

OBJECTIVE

To propose the concept of bronchoscopy-associated acute massive airway hemorrhage, analyze its impact on patients and highlight the treatment approach of acute massive airway hemorrhage without ECMO support.

DESIGNS

A retrospective cohort study.

SETTING

Include all patients who received bronchoscopy intervention therapy at Interventional Pulmonology Center of Emergency General Hospital from 2004 to December 2021.

PATIENTS

223 patients met the inclusion criteria.

INTERVENTION

Patients were divided into two groups: acute massive airway hemorrhage group (n = 29) and non-acute massive airway hemorrhage group (n = 194).

MAIN OUTCOME MEASURES

Perioperative adverse events between two groups were the main outcome. Secondary outcome was the impact of lung isolation on patient in group Acute.

RESULTS

The incidence of acute massive airway hemorrhage was 0.11%, and the incidence of non-acute massive airway hemorrhage was 0.76% in this study. There were significant differences in the incidence of intraoperative hypoxemia, lowest SpO2, hemorrhagic shock, cardiopulmonary resuscitation, intraoperative mortality, and transfer to ICU between acute group and non-acute group (P<0.05, respectively). Lung isolation was used in 12 patients with acute massive airway hemorrhage, and only 2 patients died during the operation.

CONCLUSION

Bronchoscopy-associated acute massive airway hemorrhage had more serious impact on patients due to rapid bleeding, blurred vision of bronchoscopy, inability to stop bleeding quickly, blood filling alveoli, and serious impact on oxygenation of the lung lobes. Polyvinyl chloride single-lumen endotracheal intubation for lung isolation, with its characteristics of low difficulty, wide applicability and available in most hospitals, may reduce the intraoperative mortality of patients with bronchoscopy-associated acute massive airway hemorrhage.

TRIAL REGISTRATION

Chinese Clinical Trial Registry on 13/03/2022.

REGISTRATION NUMBER

ChiCTR2200057470.

Glue ablation of Rasmussen's aneurysm in a case of epituberculosis

A woman in her 40s presented with massive haemoptysis and breathlessness for 1 day. She had been diagnosed with pulmonary tuberculosis based on sputum CBNAAT (Cartridge Based Nucleic Acid Amplification Test) and was on antitubercular treatment for previous 2 weeks. Her chest X-ray showed right middle lobe lateral segment dense consolidation with bilateral nodular infiltrates. CT pulmonary angiography (CTPA) revealed a well-defined homogenously enhancing vascular lesion of size 10×11×13 mm in the right hilar region communicating with the descending branch of right pulmonary artery, suggesting a Rasmussen's aneurysm. It was in close proximity to the segmental bronchus that was almost completely occluded, suggesting epituberculosis. Transvenous pulmonary artery glue embolisation successfully achieved complete ablation of the aneurysm with preserved arterial flow. She has later completed 6 months of antitubercular treatment and is cured with no recurrence of haemoptysis. Her lung infiltrates have resolved with some lung scarring.

Fiberoptic bronchoscopy combined with urokinase therapy for the treatment of fatal massive hemoptysis: A case report

BACKGROUND

Fatal massive hemoptysis is a life-threatening emergency in the respiratory system. Currently, the treatment methods and techniques for massive hemoptysis are still limited, and there are often issues of delayed treatment or improper methods in clinical practice, leading to the difficulty of rescuing patients and high mortality rates. When fatal massive hemoptysis occurs, the key to successful treatment lies in whether intrapulmonary blood clots can be effectively cleared and airway patency can be ensured. Our practice of combining fiberoptic bronchoscopy with urokinase treatment to clear intrapulmonary blood clots after fatal massive hemoptysis demonstrates the effectiveness of this method.

CASE SUMMARY

We report a 32-year-old female who experienced cough, accompanied by fatal massive hemoptysis with extensive blood clot obstruction in the airway. Considering the difficulty of clearing the airway using conventional methods, it was decided to perform fiberoptic bronchoscopy combined with urokinase therapy after reviewing relevant literature. After treatment, the intrapulmonary blood clots were successfully extracted, thereby relieving airway obstruction. Finally, the patient was successfully weaned off extracorporeal membrane oxygenation, extubated, and evacuated from the ventilator. Currently, the patient's condition is stable, and follow-up chest X-ray as well as computed tomography scans have shown improvement compared to previous assessments.

CONCLUSION

Fatal massive hemoptysis is a intractable emergency in clinical practice. In this case, we confirmed that fiberoptic bronchoscopy combined with urokinase therapy may be effective and safe in the treatment of fatal massive hemoptysis.

Hemoptysis in Cancer Patients

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

An overview on the principles of management of haemoptysis

Haemoptysis is a frequently encountered presentation in thoracic surgery practice. Most of the patients present with chronic haemoptysis while 5% of them will present with life-threatening acute haemoptysis. Emergency surgery used to be the first-line management in acute life-threatening haemoptysis which resulted in significant morbidity and mortality. With advancements in interventional procedures, most of these acute presentations are now being managed conservatively by interventionists. In a country like India with a high incidence of tuberculosis and other infectious diseases of the lungs, haemoptysis is even more common. While interventional procedures help to tide over the crisis and earn valuable time to stabilise a haemorrhaging patient, surgical resection is the definitive management most of the time. This review will endeavour to establish the definition, aetiology, emergency, and definitive management of a patient who presents with haemoptysis.

Prophylactic epinephrine attenuates severe bleeding in lung transplantation patients undergoing transbronchial lung biopsy: Results of the PROPHET randomized trial

BACKGROUND

Severe hemorrhage is an uncommon yet potentially life-threatening complication of transbronchial lung biopsy. Lung transplantation recipients undergo multiple bronchoscopies with biopsy and are considered to be at an increased risk for bleeding from transbronchial biopsy, independent of traditional risk factors. We aimed to evaluate the efficacy and safety of endobronchial administration of prophylactic topical epinephrine in attenuating transbronchial biopsy-related hemorrhage in lung transplant recipients.

METHODS

The Prophylactic Epinephrine for the Prevention of Transbronchial Lung Biopsy-related Bleeding in Lung Transplant Recipients study was a 2-center, randomized, double blind, placebo-controlled clinical trial. Participants undergoing transbronchial lung biopsy were randomized to receive 1:10,000-diluted topical epinephrine vs saline placebo administered prophylactically into the target segmental airway. Bleeding was graded based on a clinical severity scale. The primary efficacy outcome was incidence of severe or very severe hemorrhage. The primary safety outcome was a composite of 3-hours all-cause mortality and an acute cardiovascular event.

RESULTS

A total of 66 lung transplantation recipients underwent 100 bronchoscopies during the study period. The primary outcome of severe or very severe hemorrhage occurred in 4 cases (8%) in the prophylactic epinephrine group and in 13 cases (24%) in the control group (p = 0.04). The composite primary safety outcome did not occur in any of the study groups.

CONCLUSIONS

In lung transplantation recipients undergoing transbronchial lung biopsy, prophylactic administration of 1:10,000-diluted topical epinephrine into the target segmental airway before biopsy attenuates the incidence of significant endobronchial hemorrhage without conveying a significant cardiovascular risk. (ClinicalTrials.gov identifier: NCT03126968).

Endovascular treatment for life-threatening hemoptysis due to rupture of descending thoracic aortic aneurysm: A case series

INTRODUCTION AND IMPORTANCE

Aortic aneurysm is an uncommon but life-threatening cause of hemoptysis. Treatments include surgery and/or endovascular intervention, each with its own advantages and disadvantages. Endovascular intervention is associated with good early and medium-term outcomes.

CASE PRESENTATIONS

We report three cases of hemoptysis due to ruptured thoracic aortic aneurysm who underwent endovascular intervention. In all three cases, endovascular grafts were placed in the descending thoracic aorta, the number of grafts used was 1, the average time to stop hemoptysis was 4 to 5 days, and the length of hospital stay was between 6 and 8 days. No intravascular fistula, renal failure, prolonged mechanical ventilation and other major cardiovascular events were reported.

CLINICAL DISCUSSION

Endovascular treatment for descending TAA has been demonstrated to be safe and effective, particularly in emergencies in which patients presented with life-threatening hemoptysis, due to its rapid access to the aorta. In our experience at a tertiary hospital in southern Vietnam, the procedural time for a thoracic endovascular aortic repair is relatively brief and can last between 15 and 30 min. Thus, endovascular treatment for ruptured TAA can substantially improve patient prognosis, reduce mortality and complications.

CONCLUSION

The implementation of endovascular intervention can help improve prognosis, reduce mortality and complications in patients with hemoptysis due to ruptured thoracic aortic aneurysm.

Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

The Use of a Fabricated Endotracheal Tube During an Acute Massive Pulmonary Hemorrhage: A Case Report

A massive pulmonary hemorrhage is an emergency that can lead to airway compromise and cardiovascular collapse. The goals of airway management are to isolate and protect the nonbleeding lung while providing a route for interventions to diagnose and control the bleeding site. We present a case of an adult male with a lung mass who underwent a bronchoscopy and cryobiopsy that was complicated by a massive pulmonary hemorrhage. We report the successful use of an elongated fabricated end-to-end endotracheal tube to manage his airway during this time-critical situation.

[Haemoptysis]

Haemoptysis describes the expectoration of blood originating from the tracheobronchial tree and lung. Its presentation varies from mild to massive haemoptysis, the latter entailing the risk of asphyxia and thus requiring rapid intervention that spans multiple specialties.

Endovascular Plug for Endobronchial Management of an Expectorated Pulmonary Artery Embolization Coil: A Case Report

Pulmonary artery aneurysms are frequently managed with endovascular embolization. Rare but serious complications of coil embolization are erosion and migration of the coils into the adjacent airways, posing a risk for massive hemoptysis. We report the case of a medically complex patient with a left main pulmonary artery aneurysm treated with coil embolization who ultimately experienced transbronchial migration and expectoration of the coil. We discuss the challenging anesthetic and surgical management of these serious complications, including the use of an endovascular plug to occlude the erosion site and distal airways.

Mycobacterium avium Complex Lung Disease Complicated With Antiglomerular Basement Membrane Disease: A Case Report

While both Mycobacterium avium complex (MAC) lung diseases and antiglomerular basement membrane (anti-GBM) antibody disease may cause hemoptysis, no case presenting hemoptysis having both diseases has been reported. A woman in her 80s was admitted due to hemoptysis with acute respiratory failure. MAC was isolated from her sputum, and a positive report for anti-GBM antibody was confirmed in screening for hematuria. This patient has been successfully treated with systemic corticosteroid therapy followed by combination chemotherapy against MAC. Although anti-GBM disease is a rare condition, screening might be recommended in case of uncontrollable hemoptysis as MAC lung disease with hematuria.

Management of recurrent hemoptysis: a single-center experience

BACKGROUND

A successful planning methodology for patients with hemoptysis promises overall improvement in patient care. Conducted in a reference center for chest diseases, the present study aims to analyze characteristics and predictors of interventional methods in patients with recurrent hemoptysis.

METHODS

The present study is a single-center, retrospective observational study. Between 2015 and 2018, 5973 patients with follow-up data until 2021 requiring more than one hospitalization due to recurrent hemoptysis were investigated. Patient characteristics, the amount of hemoptysis, baseline admission parameters, interventional procedures of bronchial artery embolization (BAE), fiberoptic bronchoscopy, rigid bronchoscopy, and surgical resections applied were analyzed according to number of hospitalizations and outcome.

RESULTS

: Hospital admission numbers were higher in patients with sequela of tuberculosis, bronchiectasis and lung cancer. While lung cancer was the most frequent underlying reason in recurrent admissions, it was determined that as the amount of bleeding increased, the number of admissions also increased to the hospital, and BAE and rigid bronchoscopy were performed more frequently in the groups with less frequent admissions. There was no statistically significance between the amount of bleeding, and the interventional procedure alone or in combination with another procedure (p > 0.05).

DISCUSSION

In conclusion, patients with certain diseases may experience frequent hospital admissions due to hemoptysis. Recurrent admissions may get better results with BAE and rigid bronchoscopy. We think that these procedures should be preferred in the foreground of suitable patient selection in line with available facilities and experience.

A 22-Year-Old Man Coughs Blood

A 22-Year-Old Man Coughs BloodA 22-year-old man sought evaluation after coughing up foul-smelling, brown sputum mixed with bright-red blood. Symptoms were preceded by chest pain in the left parasternal region that was worse on deep inspiration. Using questions, physical examination, and testing, an illness script for the presentation emerges. The differential is refined until a final diagnosis is made.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

Serial platelet level index improves prediction of pulmonary hemorrhage in patients with Stenotrophomonas maltophilia respiratory infections and thrombocytopenia

Patients with thrombocytopenia (platelet count &lt;150 × 103/μL) often develop pulmonary hemorrhage (PH) after Stenotrophomonas maltophilia (SM) respiratory infection, resulting in a high respiratory failure rate and increased mortality. Developing an efficient method for early prediction of PH in these patients may improve survival. This study aimed to evaluate risk factors in PH and to develop an index measuring serial platelet deficit to predict PH in patients with SM respiratory infection. Data of patients with SM respiratory infection and thrombocytopenia treated in a tertiary university hospital during 2018–2020 were retrospectively retrieved from electronic medical records and analyzed. SM respiratory infection was defined as SM isolated from sputum, endotracheal suction, or bronchial alveolar lavage plus acute respiratory symptoms. Between PH and non-PH groups, clinical characteristics and laboratory parameters were collected and compared. The newly developed platelet dissimilarity index (d-index) was calculated by accumulating differences between the actual and the lowest normal level of the platelet count in each patient at different time points. Within 1,039 patients with positive SM culture, 437 cases matched the criteria and were analyzed. A total of 125 (28.6%) patients developed PH and 312 (71.4%) did not. The patients with PH had increased prothrombin time/international normalized ratio (PT/INR), lower platelet count, and higher platelet d-index. Multivariate analysis revealed that extreme thrombocytopenia (platelet count &lt;50 × 103/μL) is a common independent risk factor in PH and mortality. The performance of platelet deficit and d-index varied between patients with different comorbidities. Performance of platelet deficit to predict PH is better in patients with hematology/oncology or liver disease (area under curve, 0.705–0.757), while d-index is better in patients with sepsis/treatment and various other groups (0.711–0.816). Prolonged and extreme thrombocytopenia is a determinant risk factor in PH in patients with SM respiratory infection. Given the complexity of causes of thrombocytopenia and associated comorbidities, different strategies should be applied when assessing the risk for PH.

Blush in Lung Contusions Is Not Rare and Has a High Risk of Mortality in Patients With Blunt Chest Trauma

Background

Patients with blunt chest trauma have a high mortality rate. The assessment of blush in hepatic and splenic trauma is important for determining the need for emergency hemostatic interventions. However, the frequency and importance of blush in lung contusions are unknown. Therefore, this study aimed to evaluate the frequency of blush in patients with lung contusions and elucidate the relationship between blush and the clinical outcomes of patients with blunt chest trauma.

Materials and Methods

In this retrospective observational study, we enrolled patients with an injury severity score of 16 or higher and a chest abbreviated injury scale (AIS) score of 3 or higher who were admitted to the emergency department of Hokkaido University Hospital from January 1, 2003, to December 31, 2016. Blush was defined as active extravasation of an intravascular contrast agent recognized on contrast-enhanced computed tomography. The date of trauma, trauma severity, treatments, and outcomes were obtained from the patients’ electronic medical records.

Results

During the study period, 83 patients had severe lung contusions and 13 had blush. In-hospital mortality of patients with blush was significantly higher than that of patients without blush (53 vs. 10%, P &lt; 0.001). Patients with blush required thoracic drainage more frequently (100 vs. 71%, P &lt; 0.001) and support through mechanical ventilation more often (100 vs. 64%, P &lt; 0.001) and for a longer duration (median duration, 0 vs. 25 days, P = 0.001) than patients without blush.

Conclusions

Our study revealed that blush in lung contusions was not rare and was associated with a high risk of mortality in patients with severe blunt chest trauma. Clinicians should not hesitate to intervene if blush is detected in a lung contusion of a patient with blunt chest trauma.

A retrospective analysis of risk factors for massive hemoptysis in patients with bronchiectasis

BACKGROUND

Massive hemoptysis is a common and fatal complication of bronchiectasis. However, the risk factors for massive hemoptysis in patients with bronchiectasis have not yet been reported. This study investigated the potential risk factors for massive hemoptysis in patients with bronchiectasis.

METHODS

This retrospective study included patients with bronchiectasis and their data were obtained from medical records. The risk factors for massive hemoptysis were evaluated by multivariate analysis of patient characteristics, medical history, and computed tomography imaging data, including the number of lesions, lesion location, and laboratory findings.

RESULTS

Among 379 patients, 61 (16.09%) experienced severe hemoptysis. Multivariate analysis revealed that diabetes (odds ratio (OR) 2.885; 95% confidence interval (CI) 1.009-8.247), lesions involving two lobes (OR 4.347; 95% CI 1.960-9.638) and three lobes (OR 2.787; 95% CI 1.055-7.363) were significant predictors of severe hemoptysis. However, a disease course between 1 and 5 years (OR 0.300; 95% CI 0.112-0.801) and involvement of the left lower lobe (OR 0.394; 95% CI 0.196-0.793) were protective factors for the prevention of massive hemoptysis. Lesions in the right upper lobe were more likely to cause massive hemoptysis (OR 1.458) than involvement of other lobes.

CONCLUSIONS

Diabetes and lesions involving two and three lobes, were risk factors for massive hemoptysis in patients with bronchiectasis. Disease duration between 1 and 5 years and involvement of the left lower lobe were protective factors, while lesions in the right upper lobe had a stronger relationship with massive hemoptysis in patients with bronchiectasis.

ABCDE Approach for Massive Hemoptysis: A Novel Cognitive Aid

Massive hemoptysis is a high-risk, low-frequency clinical scenario, and teaching the management of this emergency should extend beyond reliance on clinical exposure. Massive hemoptysis requires emergent intervention to avoid asphyxiation and death. Practitioners need both cognitive and procedural skills to intervene in a high-stress situation. Cognitive aids have demonstrated benefits in other emergency settings, but no such tool exists for massive hemoptysis. Using expert recommendations, we developed the ABCDE Approach for Massive Hemoptysis, a cognitively accessible, prioritized toolbox of interventions designed to assist learners in organizing an approach to these high-risk and time-sensitive patient cases. Herein we present the elements and use of the ABCDE approach. Providing a cognitive approach to massive hemoptysis is an important first step in improving education for this potentially fatal clinical scenario.

Bronchial Artery Embolization

Massive hemoptysis is a highly morbid medical condition with up to 75% mortality with conservative treatment. Bronchial artery embolization has emerged as the common treatment for both acute massive hemoptysis and chronic hemoptysis. This article will review the clinical presentation, bronchial artery anatomy, embolization procedure, complications, and expected outcomes.

Pulmonary Artery Bleed from an Eloesser flap

An open thoracic window involves the creation of a semi-permanent pleural-cutaneous connection to treat chronic organising empyemas, bronchopleural fistulas and postpneumonectomy empyemas in patients too ill for video-assisted thoracic surgery decortication. An Eloesser flap is a type of open thoracic window. Antibiotics have made the use of Eloesser flaps and other open thoracic windows for treatment of empyemas rare. Consequently, not much is known about the chronic complications of open thoracic windows. However, structural compromise of vasculature secondary to chronic inflammation has been previously proposed as a mechanism for spontaneous pulmonary haematomas related to anatomic deformation. We depict a case of spontaneous pulmonary arterial bleed presenting as chest wall haemorrhage due to a chronic modified Eloesser flap.

Comparative Study of Diagnostic Efficacy of Single Phase-Computed Tomography Pulmonary Angiography and Dual Phase-Computed Tomography Pulmonary Angiography in the Diagnosis of Pulmonary Embolism

Objective

We compared the efficacy of single phase-computed tomography pulmonary angiography (SP-CTPA) and dual phase-computed tomography pulmonary angiography (DP-CTPA) for the diagnosis of pulmonary embolism (PE).

Methods

We recruited 1,019 consecutive patients (359 with PE) who underwent DP-CTPA (phase I: pulmonary artery phase; phase II: aortic phase) for suspected PE between January and October 2021. Phase I of DP-CTPA was used as SP-CTPA, and the final clinical diagnosis (FCD) was used as the gold standard.

Results

Three hundred fifty-two cases of PE were detected by both methods, with the same sensitivity of 98.1% (99.6–99.5%). Using SP-CTPA, 142 cases [13 pulmonary insufficiency artifacts (PIA) and 129 systemic-pulmonary shunt artifacts (S-PSA)] were false-positive with specificity of 78.5% (75.3–81.6%). No false-positive was found with DP-CTPA, with specificity of 100%, positive predictive value of 1, and negative predictive value of 0.990 (Net Reclassification Improvement = 0.215; P < 0.05). According to FCD, the positive results of SP-CTPA were divided into PIA, S-PSA, and true-positive (TP_SP−CTPA) groups, and pairwise comparisons were performed. The bronchiectasis and hemoptysis rate in S-PSA group was higher than that in PIA and TP groups (P < 0.001), and the pulmonary hypertension (PH) rate in PIA group was higher than that in S-PSA and TP groups (P < 0.001).

Conclusion

The diagnostic efficiency of DP-CTPA for the diagnosis of PE was high. SP-CTPA may misdiagnose PIA (common in patients with PH) and S-PSA (common in patients with bronchiectasis and hemoptysis) as PE.

Haemoptysis in Pulmonary Arterial Hypertension Associated with Congenital Heart Disease: Insights on Pathophysiology, Diagnosis and Management

Haemoptysis represents one of the most severe major bleeding manifestations in the clinical course of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD). Accumulating evidence indicates that dysfunction of the pulmonary vascular bed in the setting of PAH predisposes patients to increased hemorrhagic diathesis, resulting in mild to massive and life-threatening episodes of haemoptysis. Despite major advances in PAH targeted treatment strategies, haemoptysis is still correlated with substantial morbidity and impaired quality of life, requiring a multidisciplinary approach by adult CHD experts in tertiary centres. Technological innovations in the field of diagnostic and interventional radiology enabled the application of bronchial artery embolization (BAE), a valuable tool to efficiently control haemoptysis in modern clinical practice. However, bleeding recurrences are still prevalent, implying that the optimum management of haemoptysis and its implications remain obscure. Moreover, regarding the use of oral anticoagulation in patients with haemoptysis, current guidelines do not provide a clear therapeutic strategy due to the lack of evidence. This review aims to discuss the main pathophysiological mechanisms of haemoptysis in PAH-CHD, present the clinical spectrum and the available diagnostic tools, summarize current therapeutic challenges, and propose directions for future research in this group of patients.

Single-Use and Reusable Flexible Bronchoscopes in Pulmonary and Critical Care Medicine

Flexible bronchoscopy plays a critical role in both diagnostic and therapeutic management of a variety of pulmonary disorders in the bronchoscopy suite and the intensive care unit. In the set-ting of the ongoing viral pandemic, single-use flexible bronchoscopes (SUFB) have garnered attention as various professional pulmonary societies have released guidelines regarding uses for SUFB given the concern for risk of viral transmission when using reusable flexible bronchoscopes (RFB). In addition to offering sterility, SUFBs are portable, easily accessible, and may be more cost-effective than RFB when considering the potential costs of treating bronchoscopy-related infections. Furthermore, since SUFBs are one time use, they do not require reprocessing after use, and therefore may translate to reduced cleaning and storage costs. Despite these advantages, RFBs are still routinely used to perform advanced diagnostic and therapeutic bronchoscopic procedures given the need for optimal maneuverability, handling, angle of deflection, image quality, and larger channel size for passing of ancillary instruments. Here, we review the published evidence on the applications of single-use and reusable bronchoscopes in bronchoscopy suites and intensive care units. Specifically, we will discuss the advantages and disadvantages of these devices as pertinent to fundamental, advanced, and therapeutic bronchoscopic interventions.

A Case Report of a 74-Year-Old Immunocompromised Host Diagnosed with Pulmonary Blastomycosis and Pulmonary Hemorrhage

Patient: Male, 74-year-old

Final Diagnosis: Blastomycosis

Symptoms: Cough • hemoptysis • shortness of breath

Medication: —

Clinical Procedure: Bronchoscopy

Specialty: Critical Care Medicine

Cryotherapy: A Safe Approach to Pulmonary Hemorrhage During VV-ECMO

The number of hospitals with veno-venous extracorporeal membrane oxygenation (VV-ECMO) capabilities is expanding. To support an ECMO program, centers must be equipped to handle associated complications such as pulmonary hemorrhage. We describe a case series of 4 patients with life-threatening pulmonary bleeding and central airway obstruction. A therapeutic approach of anticoagulation cessation coupled with cryoextraction via flexible bronchoscopy led to successful restoration of airway patency without any adverse events. A low threshold to stop anticoagulation with a strong consideration of bronchoscopy with cryotherapy for pulmonary toilet should be done in patients with pulmonary hemorrhage during VV-ECMO.

Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

Delayed presentation of massive haemoptysis from aortic aneurysm after aortic coarctation repair (a case report)

Introduction

Massive haemoptysis refers to coughing and losing a huge amount of blood in a 24-hour period. It's a life-threatening condition with high mortality rate.

Case presentation

We report a rare case of massive haemoptysis in a 60-year-old female patient who had aortic coarctation repair 30 years ago. Her Computed tomography (CT) angiography showed huge aneurysmal dilatation and dissection of the descending thoracic aorta at the site of the repair. Thoracic endovascular aortic repair (TEVAR) was done, but the patient had recurrent massive haemoptysis due to extension of the aneurysm to the aortic arch. The patient then underwent one stage surgical right to left carotid artery shunt followed by TEVAR to the aortic arch covering the left common carotid artery. The procedure was successful, and haemoptysis was controlled without any complications.

Discussion

In this case the high index of suspicion for thoracic aortic aneurysm in patients presenting with haemoptysis and prior history of coarctation repair were demonstrated.

Conclusion

massive haemoptysis in patients who had aortic coarctation repair is an alarming sign, and surgical intervention is required. TEVAR has become one of the best approaches for managing aortic aneurysm and has replaced open repair.

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Thoracic aortic aneurysms must be ruled out in those patients who present with massive hemoptysis.

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In case of aortic coarctation repair, thoracic aortic aneurysms should be considered.

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Thoracic endovascular aortic repair (TEVAR) has become one of the best approaches for managing thoracic aortic pathology.

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In patients who present with massive hemoptysis post TEVAR, aneurysms and endoleak must be ruled out.

Hemoptysis associated with percutaneous transthoracic needle biopsy: Development of critical events checklist and procedure outcomes

BACKGROUND

A percutaneous transthoracic needle biopsy (PTNB) is performed to obtain tissue for a pathologic diagnosis. A PTNB is necessary prior to the initiation of many cancer treatments. There is a risk of hemoptysis, the expectoration of blood, with the possibility for adverse, life-threatening outcomes. A critical event checklist is a cognitive aid used in an emergency to ensure critical steps are followed. To date, there are no known checklists published for management of PTNB-related, life-threatening hemoptysis. The purpose of this report is to describe the development and implementation of a critical event checklist and the adoption of the checklist into hemoptysis management.

METHODS

In March 2017, a process improvement team convened to evaluate the hemoptysis response using the Plan-Do-Study-Act (PDSA) methodology. The checklist was evaluated and updated through September 2019. The team educated Interventional Radiology (IR) clinicians on the new checklist and conducted simulations on its use. A retrospective chart review was performed on hemoptysis events between the ten-year period of October 1, 2008 and September 30, 2018 to evaluate the adoption of the checklist into practice.

RESULTS

There were 231 hemoptysis events occurring in 229 patients (2 with repeat biopsies). Prior to implementing the protocol and checklist, there were 166 (71.9%) hemoptysis events. After implementation there were 65 (28.1%) events. The median amount of documented blood expectorated with hemoptysis was 100 mL (IQR 20.0-300.0). Twenty-six patients were admitted after PTNB for reasons related to the hemoptysis event (11.3%). During the procedure, four (1.7%) patients with hemoptysis suffered a cardiac arrest. Prior to implementation of the protocol and critical events checklist, nurses positioned patients in the lateral decubitus (LD) position in 40 out of 162 (24.7%) cases. After implementation of the critical events checklist, nurses positioned patients in the LD position 42 out of 65 cases (64.6%) (OR=5.57(95% CI 2.99-10.367), p<0.001).

DISCUSSION

Interventional Radiology nurses successfully adopted the checklist into management of hemoptysis events. The reported incidence of hemoptysis suggests a need for IR teams to prepare for and simulate hemoptysis events. Future research is needed to evaluate the change in patient outcomes before and after critical events checklist implementation.

The emergency department evaluation and management of massive hemoptysis

INTRODUCTION

Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment.

OBJECTIVE

The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician.

DISCUSSION

Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology.

CONCLUSION

Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.

"Peanut saves the day": an innovative solution to massive, cryptogenic haemoptysis-a case study

Massive (or life-threatening) haemoptysis is a time-sensitive emergency encountered by a physician that requires an interdisciplinary, collaborative effort to arrest the bleeding in a prompt and timely manner. Placement of an endobronchial Watanabe spigot (EWS) to halt haemoptysis is a relatively recent technique finding its wide application in airway pathology, with the current extension of its use to bronchial bleeding. However, the lack of immediate access to EWS gives rise to the need to innovate with day-to-day materials used in routine surgical practice and available in resource-limited settings, which may serve the purpose of a spigot. In this report, we bring to light a case of life-threatening, cryptogenic haemoptysis that was managed by a novel technique of using peanut gauze as a spigot resulting in a successful endobronchial tamponade.

Novel approach of rigid bronchoscopy concurrent with cesarean section and bronchial arterial embolism for patients with massive hemoptysis during pregnancy: case reports and literature review

Massive hemoptysis can be life-threatening and is frequently encountered in clinical practice, but rare during pregnancy. There have been limited case reports of massive hemoptysis in pregnancy in patients with conditions such as Takayasu's arteritis, bronchiectasis, bronchial carcinoid tumor, and tuberculosis. The most important management is early control of the hemorrhage and airway protection. We report on 2 patients at 33 and 27 gestational weeks who were admitted to the emergency department because of massive hemoptysis. Therapeutic rigid bronchoscopy with the application of high-frequency jet ventilation was performed under general anesthesia during cesarean section to control potential bleeding and stabilize the airway; this was then followed by bronchial artery embolization (BAE) postsurgically. The lives of both mothers and infants were saved. At the 16- and 11-month follow-ups, the patients showed no symptoms. To our knowledge, this is the first report on the application of therapeutic rigid bronchoscopy concurrent with cesarean section in order to protect the airway and reduce the side effects of the subsequent treatment for both mother and fetus in hemoptysis cases. By reporting these cases and conducting a literature review, we present a novel treatment method for massive hemoptysis in pregnant patients that may improve patients' outcomes.

Emergent Lung Resection for Massive Hemoptysis From Bronchial Malformation

Bronchial arteriovenous malformations (AVMs) are usually asymptomatic findings noted on imaging but may present with massive hemoptysis following endobronchial rupture. Initial treatment usually involves transcatheter embolization with surgery reserved for refractory cases. Here, we present a patient with large-volume hemoptysis following bronchial AVM rupture. Attempted endovascular management was unsuccessful due to unfavorable anatomy and hemodynamic instability, necessitating emergent use of extracorporeal membrane oxygenation (ECMO) followed by right bilobectomy.

Critical Care of Patients With Cardiopulmonary Complications of Sarcoidosis

Sarcoidosis is a systemic inflammatory disease defined by the presence of aberrant granulomas affecting various organs. Due to its multisystem involvement, care of patients with established sarcoidosis becomes challenging, especially in the intensive care setting. While the lungs are typically involved, extrapulmonary manifestations also occur either concurrently or exclusively within a significant proportion of patients, complicating diagnostic and management decisions. The scope of this review is to focus on what considerations are necessary in the evaluation and management of patients with known sarcoidosis and their associated complications within a cardiopulmonary and critical care perspective.