You are asked to urgently review a 48-year-old male who has been in ICU for three weeks tollowing an episode of severe community-acquired pneumonia. He had a percutaneous tracheostomy sited one week ago and has now developed sudden bleeding out of his airway.

List the possible causes for the bleeding.       (30% marks)

Outline your assessment and management of the situation.            (70% marks)

[Click here to toggle visibility of the answers]

College answer

a) Possible causes

Medical

  • Coagulopathy
    • Coagulation factor deficiency
      • (related to vitamin k def from antibiotics)
    • Excess anticoagulation medication
    • Thrombocytopaenia
    • DIC from sepsis
    • Antiplatelet medications
  • Complication of pneumonia
    • Abscess
    • Neoplasm causing pneumonia now bleeding
  • Less likely
    • Non-airway – blood from mouth, nose (post NGT) or GI tract tracking past trache tube cuff
    • Cardiac – mitral stenosis, tricuspid endocarditis
    • Vascular – PE, pulmonary infarction, AVM
    • Systemic disease – Wegeners, Goodpastures, SLE

Surgical

  • Tracheostomy site
    • Granulation tissue in track
    • Innominate artery fistula (not common but very bad)
    • Thyroid artery
    • Anterior jugular vein
  • Trachea
    • Suction trauma

b) This is an emergency situation with risks of hypoxia, aspiration and hypovolaemia

Assessment and management

  • Resuscitation
  • History and examination to determine cause/contributing factors
  • Supportive therapy
  • Specific therapy

Initial management will depend on the volume and extent of bleeding. Even small amounts of bleeding from a tracheostomy are potentially life threatening as may clot and occlude airway.

Resuscitation

  • 100% FiO2
  • Ensure airway clear
    • Pass suction catheter, suction blood only if necessary, repeated suctioning may exacerbate problem, may need to change inner cannula
    • If ventilation not possible via trache, may need to reintubate orally (pass ETT distal to stoma) to allow ventilation and protect distal airway from soiling
  • Ventilate with safe volume and pressure limits as able
  • Nurse in lateral decubitus position with bleeding lung (if known) down
  • Ensure adequate venous access, fluid resuscitation as needed, check coagulation status and platelet count, organise factor replacement as required.
  • In the case of exsanguination/brisk bleeding will need to enlist assistance of ENT +/- cardiothoracic surgery +/- interventional radiology

History and examination

Once initial situation settled, obtain history and perform examination of tracheostomy site to determine likely contributing factors from the above list of potential causes e.g. difficulty performing tracheostomy, progress of pneumonia, medications, recent blood results, comorbidities, suction technique.

Investigations 

  • Fibre-optic bronchoscopy to identify bleeding site
  • Coagulation profile and ROTEM/TEG
  • CXR
  • CT/CTPA if adequately stable

Specific treatment

Will depend on the cause identified:

  • Granulation tissue – as per surgical site bleeding with lower threshold for surgical exploration 
  • Tracheo-inominate artery fistula (TIF) – bronchoscopy and angiography may fail to identify the source. TIF should be suspected in any patient suffering major haemoptysis post tracheostomy insertion. Management consists of over inflation of the tracheostomy cuff. If this fails to control bleeding then distal orotracheal intubation (tip at or beyond carina) followed by digital insertion through the pretracheal space and compression of innominate artery against the manubrium. This should be followed by urgent surgical exploration.
  • Use of bronchial blocker / double lumen tube
  • Bronchial artery embolization
  • Surgical lobectomy or pneumonectomy if embolization fails
  • Correction of coagulopathy – consider TXA
  • Antimicrobial agents for infection
  • Immunosuppression for underlying vasculitis
  • Treatment of less likely causes as indicated

Additional Examiners’ Comments:

Candidates were not expected to provide the level of detail in the answer template. The management component required resuscitation and specific management for pulmonary haemorrhage and tracheostomy related haemorrhage including innominate-tracheal fistula. Several candidates failed to mention this pathology or its management.

Discussion

A more generic discussion of massive haemoptysis is carried out in the linked chapter. The etymology nerd would point out that can't call this airway bleeding "haemoptysis" because strictly speaking the Greek word "ptusis" means "to spit", and the trache patient's bloody cough is bypassing the mouth and lips. 

The list of differentials could be broad, but for a 30% answer one would not go about reproducing the massive table of differentials such as the one offered by Sakr et al in their 2010 article. A short list would suffice. How about this:

Causes related to the tracheostomy:

  • Erosion into tracheal wall
  • Tracheo-innominate fistula
  • Tracheo-oesophageal fistula (i.e. this could be haemtemesis)

Causes related to the pneumonia

  • Lung abscess
  • Mycotic aneurysm of a pulmonary artery

Causes unrelated to either

  • Bronchial AVM
  • Pulmonary embolism
  • Lung tumour
  • Platelet disorder or coagulopathy
  • Coagulopathy

Management is generic, and is cut-and-pasted here from Question 2 from the first paper of 2012.

1) Control the airway.

  • Assess patency of the tracheostomy
    • Replace inner cannula
    • Assess the possibility of bronchoscopy via the tracheostomy
    • If impossible, intubate the patient with a large-bore tube to permit bronchoscopy (i.e. remove the tracheostomy.
    • If you are skilled and the pathology is unilateral, a dual-lumen tube could be considered
  • Position the patient in a Trendelenberg position, or with the bleeding lung dependent.

2) Control the breathing.

  • Ventilate the patient with the bad lung dependent, to prevent contralateral lung soiling
  • Increase the PEEP, to get the benefit of whatever tamponade effect it might provide.

3) Control the circulation.

  • Replace the lost blood and stabilise the hemodynamic variables

4) Control the bleeding

  • Reverse any coagulopathy
  • Perform bronchoscopy
    • Suck out any obvious clots
    • Place a balloon-tipped catheter to put pressure on the bleeder
    • Burn the bleeder with argon plasma (if you have the tools)
  • Perform angio-embolisation if bleeding is not controlled. Angio-embolisation is a pretty cool modality, with a low complication rate.
  • Send the patient to thoracotomy if angio-embolisation is impossible

5) Control the cause

  • Antibiotics for tuberculosis and fungal abscesses
  • Surgery or radiotherapy for cancers
  • Immunosuppression for vasculitis
  • Surgery for AVMs

References

References

Adlakha, Amit, et al. "LONG-TERM OUTCOME OF BRONCHIAL ARTERY EMBOLISATION (BAE) FOR MASSIVE HAEMOPTYSIS.Thorax (2011).

Talwar, D., et al. "Massive hemoptysis in a respiratory ICU: causes, interventions and outcomes-Indian study." Critical Care 16.Suppl 1 (2012): P81.

Sakr, L., and H. Dutau. "Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management." Respiration 80.1 (2010): 38-58.

Ibrahim, W. H. "Massive haemoptysis: the definition should be revised." European Respiratory Journal 32.4 (2008): 1131-1132.

Corey, Ralph, and Khin Mae Hla. "Major and massive hemoptysis: reassessment of conservative management." The American journal of the medical sciences 294.5 (1987): 301-309.

Amirana, M., et al. "An Aggressive Surgical Approach to Significant Hemoptysis in Patients with Pulmonary Tuberculosis 1, 2, 3." American Review of Respiratory Disease 97.2 (1968): 187-192.