Hemoptysis in morbidly obese patient

Case: 58 years old morbidly obese patient known to have difficult intubation is in ICU after Pulmonary Embolism (PE) and is on anticoagulation. Patient developed massive life-threatening hemoptysis. The next step is - select one.

A) Bilevel positive airway pressure (BIPAP)

B) Nasotracheal intubation 

C) Call Anesthesia backup for intubation

D) Avoid intubation and apply nasal prongs 

E) Make patient DNR

Answer: C

In life-threatening hemoptysis, maneuvers should be initiated instantly, such as putting the presumed bleeding side of the lung down and calling to prepare for intubation. In anticipated difficult intubation, all backup should be called, such as a difficult airway cart, bronchoscope, and more experienced operator available in the hospital. An endotracheal tube (ETT) size 8 or greater is preferred for a bronchoscope to apply a bronchial blocker and facilitate blood and thrombus extraction.

BIPAP (Choice A) should be avoided at all costs as it may cause aspiration pneumonia and even choking to death.

Nasotracheal intubation (choice B) is not recommended as the ETT size is usually too small to perform any procedure beyond it.

Avoiding intubation (Choice D) will not help stabilize the patient. This route should be reserved only for Do Not Intubate (DNI) category patients. Even in such cases, discussion with the patient and/or family should be ensured if the situation is curable and appears short-lived.

Choice E is incorrect, as not treating a curable disease is an unethical practice at all levels.

One objective of this question is to establish that airway management is a life-saving skill and that a very low threshold should be kept for seeking help.

#procedures

#pulmonary

References:

1. Ong TH, Eng P. Massive hemoptysis requiring intensive care. Intensive Care Med. 2003 Feb;29(2):317-20. doi: 10.1007/s00134-002-1553-6. Epub 2002 Nov 2. PMID: 12594593.

2. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017 Sep;9(Suppl 10):S1069-S1086. doi: 10.21037/jtd.2017.06.41. PMID: 29214066; PMCID: PMC5696556.

3. Katkov WN, Ault MJ. Endotracheal intubation in massive hemoptysis: advantages of the orotracheal route. Crit Care Med. 1989 Sep;17(9):968. doi: 10.1097/00003246-198909000-00027. PMID: 2766774.

4. Charya AV, Holden VK, Pickering EM. Management of life-threatening hemoptysis in the ICU. J Thorac Dis. 2021 Aug;13(8):5139-5158. doi: 10.21037/jtd-19-3991. PMID: 34527355; PMCID: PMC8411133.