Bleeding into the Airway – Presentation of a Case and Approaches to Management
Zachary Bird MD, David A. Paulus MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
Bleeding into the airway presents a difficult clinical challenge, because of
the large number of causes, resulting in a host of sypmtomatic and causal
treatment options. Our case illustrates the intraoperative management of a
bleeding airway in a patient scheduled for cardiac surgery.
Case Report
A 75-year-old woman was transferred to our hospital after a recent
myocardial infarction for urgent coronary artery bypass grafting. Coronary
angiography showed severe coronary artery disease and a low ejection
fraction. Her medical history included hypertension, remote history of chest
pain, degenerative joint disease, and hypercholesterolemia. In addition she
had a current respiratory tract infection.
In preparation for surgery cardiac output and coronary perfusion pressure
were augmented by intraaortic balloon counterpulsation. After anesthetic
induction she was noted to have a sudden increase of peak airway pressure
and frothy blood in the endotracheal tube. Inspired oxygen was increased to
100%. Her airway was suctioned/lavaged and a clot was removed from the
endotracheal tube. A fiberoptic bronchoscopy was performed, but no definite
pathology was detected. The planned opeationwas cancelled and the patient
was transferred to the intensive care unit. Later that day a formal rigid
bronchoscopy was done, which showed a well-formed clot in the right upper
lobe. Again no signs of trauma, localized infection or cancer were found.
Much speculation exists on how our patient developed bleeding into the
airway while under anesthesia. Part of the differential diagnosis includes:
pulmonary hypertension, bronchitis, cystic fibrosis, pneumonia, lung
abscess, tuberculosis, bronchiectasis, aspergilloma, broncholithiasis,
neoplasm, vascular anomalies, and pulmonary embolism. Treatment options we
considered for our patient included: placing the bleeding side down, placing
a double-lumen endotracheal tube to isolate the right from left lung, 100%
oxygen, fresh frozen plasma, platelets, desmopressin, iced saline with
epinephrine lavage, and angiography with embolization.
In conclusion our patient had marked structural heart disease, a compromised
coagulation status, and a respiratory tract infection resulting in inflamed
and weakened lung parenchyma. The proximate event was the institution of
positive pressure ventilation, which, in this setting, led to spontaneous
bleeding in the airway. Our case illustrates one combination of therapeutic
and diagnostic steps to address this potentially fatal complication.
