Pulmonary hemorrhage is a life-threatening emergency characterized by severe, acute lung bleeding. It may cause gas exchange problems, airway obstruction, and hemodynamic compromise.
In the perioperative period, it:
May be present as a medical emergency in which an anesthesia provider is asked to assist airway management.
May occur intraoperatively as an acute process or complication (surgery, pulmonary artery catheterization, airway management).
Epidemiology
Incidence
Rare complication that is reported in <1% of anesthetics
Prevalence
Ongoing pulmonary hemorrhage is very rare (it either resolves, is treated successfully, or the patient succumbs to it).
Conditions predisposing to it, such as fungal infection or tuberculosis (TB) are rare, with the prevalence dependent upon the specific population.
Morbidity
Blood or clot in the airway may cause airway/endotracheal tube obstruction.
Blood loss may cause hypovolemia or hemorrhagic shock.
Mortality
High and can exceed 50% depending upon the etiology as well as the timeliness and effectiveness of treatment.
Etiology/Risk Factors
Pulmonary infection
Cavitary TB ("Rasmussen's aneurysm")
Fungal infection
Bronchiectasis
Wegener's granulomatosis: A vasculitis affecting the nose, ears, kidneys, and lungs.
Goodpasture's syndrome: An autoimmune disease affecting the kidneys and lungs.
Infectious processes with widespread pulmonary capillary or arterial breakdown (e.g., capillaritis).
Large pulmonary capillary–alveolar hydrostatic gradient (severe pulmonary hypertension, negative pressure from airway obstruction).
Localized bleeding usually results from trauma, with the exception of cavitary infections such as TB.
Pulmonary artery rupture
Complication of pulmonary thromboendarterectomy (2) [C]
Prevantative Measures
PACs must be used with care.
"Wedge" the catheter only for good reason.
Withdraw the catheter 1–2 cm prior to inflating the balloon.
Remove the catheter gently, as there have been case reports of accidental suturing to the PA wall during cardiac surgery. General rule: If something is not easy to remove, do not use force!
Diagnosis⬆⬇
Blood appears in the airway
Dark blood usually indicates pulmonary arterial bleeding.
Bright red blood usually indicates bronchial (systemic) arterial bleeding.
History and records may reveal:
History of fungal or tuberculous infection
Recent chest trauma
Recent PAC placement
Difficult removal of a double lumen endobronchial tube after pneumonectomy (may have been accidentally sutured in place during surgery)
Difficult pulmonary thromboendarterectomy with disruption/perforation of a pulmonary artery (2) [C]
Fiberoptic bronchoscopy (FOB) is recommended to determine the source of bleeding (diffuse vs. lobar process, left vs. right). It may be necessary to perform a rigid bronchoscopy when the flexible scope is inadequate.
Differential Diagnosis
Pulmonary edema with severe capillary leak may have a hemorrhagic component.
GI bleeding (hematemesis)
Nasopharyngeal or oropharyngeal bleeding
Treatment⬆⬇
Supportive modalities:
Control the airway with placement of an endotracheal tube. Use the largest ETT feasible to allow for effective suctioning and bronchoscopy.
Provide oxygen and ventilation.
Positive airway pressure (e.g., PEEP) may help tamponade bleeding.
Consider lung isolation to keep the bleeding localized and preserve gas exchange in uninvolved lung segments (maintain V/Q matching).
Double lumen endobronchial tubes are excellent for lung isolation. However, suctioning and FOB may be difficult because of the smaller lumens. In addition, if an endotracheal tube is already in place, it should only be removed with great caution; airways may be edematous and intubation may become difficult or impossible, even with exchange catheters.
Bronchial blocker (ArndtTM, UniventTM, Fogarty catheter). However, it is not feasible to maintain lung isolation while performing a bronchoscopy or suctioning.
Correct coagulopathy if it is present.
Transfuse red blood cells as necessary
Therapeutic modalities
Consider topical vasoconstrictor; can be delivered either via an endotracheal tube or locally via FOB.
Vasopressin (2 U/mL, 20 mL)
Phenylephrine (100 mcg/mL, 20 mL)
Epinephrine (5 mcg/mL, 20 mL)
Embolization of the bleeding bronchial artery or balloon occlusion of the pulmonary artery may be performed by interventional radiologists (4) [C].
Consider lung resection or pneumonectomy for localized bleeding refractory to other treatments.
Follow-Up⬆⬇
After bleeding resolves, the assistance of the anaesthetist may be required for:
Removal of the bronchial blocker
Exchange of double lumen tube with a single lumen endotracheal tube
Weaning from mechanical ventilation and extubation
Closed Claims Data
Since it is rare, there are few closed claims data on pulmonary artery hemorrhage during anesthesia.
2 cases of pulmonary artery rupture from PAC out of a total of 3,533 claims in the ASA Closed Claims Database: http://depts.washington.edu/asaccp/ASA/index.shtml
ManeckeGRJr, KotzurA, AtkinsG, et al.Massive pulmonary hemorrhage after pulmonary thromboendarterectomy. Anesth Analg. 2004;99:672–675.
HuangGS, WangHJ, ChenCH, et al.Pulmonary artery rupture after attempted removal of a pulmonary artery catheter. Anesth Analg. 2002;95:299–301.
DopfmerUR, BraunJP, GrosseJ, et al.Treatment of severe pulmonary hemorrhage after cardiopulmonary bypass by selective, temporary balloon occlusion. Anesth Analg. 2004;99:1280–1282.
CarronH, HillS.Anesthetic management of lobectomy for massive pulmonary hemorrhage. Anesthesiology. 1972;37:658–659.
Additional Reading⬆⬇
ManeckeGRJr, KotzurA, AtkinsG, et al.Massive pulmonary hemorrhage after pulmonary thromboendarterectomy. Anesth Analg. 2004;99:672–675.
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