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)
a) Possible causes
b) This is an emergency situation with risks of hypoxia, aspiration and hypovolaemia
Assessment and management
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.
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.
Will depend on the cause identified:
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.
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:
Causes related to the pneumonia
Causes unrelated to either
Management is generic, and is cut-and-pasted here from Question 2 from the first paper of 2012.
1) Control the airway.
2) Control the breathing.
3) Control the circulation.
4) Control the bleeding
5) Control the cause
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.