Abstract Introduction Non-gestational choriocarcinoma (NGC) is a rare, highly vascular malignancy arising from germ cells, characterized by rapid hematogenous spread and a strong predilection for pulmonary metastases. These lesions are frequently hemorrhagic, predisposing to hemoptysis and resultant respiratory failure. Reports of airway compromise due to hemorrhagic pulmonary metastases in NGC are exceedingly rare. Case Report A 41-year-old female with newly diagnosed metastatic NGC was admitted for initiation of inpatient chemotherapy. Her course was complicated by worsening dyspnea, hypoxemia, and diffuse bilateral pulmonary infiltrates. She was transferred to the medical intensive care unit for rapidly progressive acute hypoxemic respiratory failure, eventually requiring intubation.During rapid-sequence intubation, preoxygenation was achieved with 100% FiO2 via bag-valve-mask ventilation. Approximately ten seconds after bag removal post-induction, oxygen saturation abruptly declined to 60%, requiring a second, more rapid attempt following resolution of hypoxemia with additional bag-valve-mask ventilation in between attempts. Following successful intubation, copious bloody secretions rapidly filled the endotracheal tube. Findings were consistent with massive hemoptysis secondary to hemorrhagic pulmonary metastases. The patient required high levels of ventilatory and vasopressor support as well as transfusions for anemia from pulmonary hemorrhage. Despite aggressive supportive care, oxygenation remained labile, consistent with extensive pulmonary vascular disruption from tumor invasion. Discussion This case illustrates rare and life-threatening acute respiratory failure secondary to metastatic NGC, in which friable pulmonary metastases caused immediate and profound desaturation during intubation. Awareness of this mechanism is essential for clinicians managing patients with hemorrhagic pulmonary metastases. Strategies to mitigate risk may include minimizing apnea time with swift intubation or partial reverse Trendelenburg positioning to avoid rapid desaturation. Recognition of this rare presentation may inform safer airway management in oncologic patients at risk for pulmonary hemorrhage. References: Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis, and management of hydatidiform mole. Am J Obstet Gynecol. 2010;203(6):531-539. Piura E. Non-gestational ovarian choriocarcinoma: a review. Eur J Gynaecol Oncol. 2006;27(6):545-550. Abrao FC, et al. Pulmonary hemorrhage caused by metastatic choriocarcinoma: case report and review. J Bras Pneumol. 2009;35(6):606-609. Karamchandani K, Wheelwright J, Yang AL, Westphal ND, Khanna AK, Myatra SN. Emergency airway management outside the operating room: current evidence and management strategies. Anesth Analg. 2021;133(3):648-662. This abstract is funded by: None
Joseph et al. (Fri,) studied this question.