C52-50 Bridging Chaos: VV-ECMO for Rescue Stabilization in Life Threatening Hemoptysis

Abstract Introduction The definition of massive hemoptysis, historically defined as 100-1,000 mL of expectorated blood within 24 hours, has evolved toward the functional concept of life-threatening hemoptysis1. Although uncommon, this condition carries a high risk of morbidity and mortality. Stabilization measures, including airway protection, selective intubation, and endobronchial tamponade, are often temporizing. Definitive therapy, such as bronchial artery embolization (BAE) or surgical resection, can be delayed or precluded by persistent clinical instability. We present a case in which veno-venous extracorporeal membrane oxygenation (VV-ECMO) was successfully utilized as a bridge to definitive treatment in refractory life-threatening hemoptysis. Case A 65-year-old man with emphysema and active tobacco use presented with small-volume hemoptysis. Computed tomography angiography (CTA) of the chest demonstrated left lower lobe (LLL) opacification with surrounding tree-in-bud centrilobular nodules. Within hours, the patient developed large-volume hemoptysis and progressive hypoxemic respiratory failure, prompting emergent intubation. Bronchoscopy revealed extensive fibrinous clot burden in the left bronchial tree with suspected bleeding originating in the LLL, and an endobronchial blocker was placed. Bronchial artery angiogram identified a diminutive, irregular LLL bronchial artery, though embolization was technically unsuccessful. Despite repeated bronchoscopic interventions and maximal ventilator support, the patient developed refractory hypoxemic and hypercarbic respiratory failure with a minute ventilation of 1L/min. VV-ECMO was initiated as a salvage measure to allow bronchoscopic clot removal. Heparin was bolused for cannulation, after which no anticoagulation was administered during the 7 days on circuit, and ECMO flow rates 4 L/min were maintained to minimize circuit thrombosis. Improved oxygenation and ventilation allowed further bronchoscopic evaluation, and a repeat left lower BAE was performed successfully. The patient was successfully decannulated on ECMO day 7, liberated from mechanical ventilation, and subsequently discharged home without recurrent hemoptysis. Discussion While BAE remains a cornerstone for definitive treatment, safely bridging unstable patients to receive these procedures is complex. While there are case reports of using VV ECMO in cases of massive hemoptysis, current Extracorporeal Life Support Organization (ELSO) guidelines neither endorse nor oppose ECMO use in massive hemoptysis, reflecting a gap in robust evidence to support its use in this clinical context3, 4,5. Our case adds to the emerging literature that VV-ECMO without long-term continuous anticoagulation can be used to bridge unstable patients to stabilization and definitive therapy for hemoptysis. As ECMO applications continue to expand, further studies and registry data are needed to establish standardized protocols and clarify outcomes in this rare but devastating condition. This abstract is funded by: None