Abstract Introduction The underlying etiology and anatomic focus of acute massive pulmonary hemorrhage can be difficult to isolate, especially when imaging is nonspecific. We present a case of massive hemoptysis in which intubation with double-lumen endotracheal tube (DL-ETT) had diagnostic and therapeutic utility. History A previously healthy 15-year-old female presented to the emergency department after acute massive hemoptysis (∼375 ml frank red blood). Past medical, family, and infectious exposure histories were all unremarkable. Chest radiograph demonstrated nonspecific right lower lobe opacities (Fig. 1A), so chest computed tomography angiography (CTA) with arterial phase contrast was obtained. This was notable for right-greater-than-left scattered opacities without arterial extravasation to suggest locus of hemorrhage. The patient remained stable for several hours until another hemoptysis episode prompted urgent diagnostic flexible bronchoscopy rather than thoracic angiography (TA) as CTA did not identify an arterial bleeding source. To allow for better visualization of hemorrhagic focus and in coordination with pediatric anesthesia team, a DL-ETT was placed. Initially, the left mainstem bronchus was occluded by ETT balloon. Right-sided lobes had several bloody clots, but no evidence of active bleeding. Shortly thereafter, the patient demonstrated brisk, pulsatile bleeding filling the right ETT lumen. Subsequent balloon occlusion of the right mainstem bronchus allowed for tamponade and enabled left side evaluation, which showed scant blood, but no evidence of active hemorrhage. Given bronchoscopy findings compatible with right-sided arterial bleed, interventional radiology (IR) was consulted for emergent TA. TA demonstrated hemorrhage from a hypertrophied right-sided bronchial artery (Fig. 1C), which was subsequently embolized to stasis. The patient was transferred to the intensive care unit with DL-ETT in place and extubated the following morning without further hemoptysis. Discussion This case highlights the utility of DL-ETT in pediatric patients presenting with massive hemoptysis of unknown etiology. Given the intermittent hemoptysis and small size of affected vessel, arterial phase CTA did not show active bleeding, which prompted diagnostic bronchoscopy. Isolating the source of an active pulmonary hemorrhage by bronchoscopy can be challenging, but in this case, it was optimized by utilizing a DL-ETT to isolate each lung for independent evaluation and prevent bleeding into the contralateral lung. Furthermore, having DL-ETT in place at initial intubation allowed for effective independent lung ventilation and tamponade during an active hemorrhage episode until definitive management by IR. One notable limitation of DL-ETTs is the smaller lumen size, which limits the bronchoscope working channel size should interventional tools be clinically necessary. This abstract is funded by: None
Kapoor et al. (Fri,) studied this question.