What is the cause of bloody secretions in the endotracheal tube (ETT)?

From the Guidelines

Bloody endotracheal tube secretions should be managed promptly with gentle suctioning and assessment of the patient's vital signs and oxygen saturation, as they may indicate a life-threatening condition such as pulmonary hemorrhage or airway trauma, with a significant increase in mortality rate associated with tracheostomy-related haemorrhage, as seen in a study published in the British Journal of Anaesthesia 1.

Initial Assessment and Management

The first step in managing bloody endotracheal tube secretions is to evaluate the patient's vital signs and oxygen saturation, as this finding may indicate pulmonary hemorrhage or airway trauma. Suction the airway using a closed suction system with gentle technique to clear secretions while avoiding further trauma. Increase FiO2 temporarily to maintain adequate oxygenation during assessment.

• Evaluate the patient's vital signs, including heart rate, blood pressure, and respiratory rate
• Assess oxygen saturation and adjust FiO2 as needed
• Suction the airway using a closed suction system with gentle technique

Diagnostic Evaluation

Obtain a portable chest X-ray to evaluate for potential causes such as pneumonia, pulmonary contusion, or pulmonary edema. Consider collecting samples for laboratory analysis including complete blood count, coagulation studies, and microbiological cultures.

• Obtain a portable chest X-ray to evaluate for potential causes
• Collect samples for laboratory analysis, including complete blood count, coagulation studies, and microbiological cultures

Management

Management depends on the severity of the bleeding - for minor bleeding, continue gentle suctioning and monitoring; for moderate to severe bleeding, consider pulmonary consultation, bronchoscopy for direct visualization, correction of any coagulopathy with appropriate blood products, and treating underlying causes with antibiotics if infection is present.

• Continue gentle suctioning and monitoring for minor bleeding
• Consider pulmonary consultation, bronchoscopy, and correction of coagulopathy for moderate to severe bleeding
• Treat underlying causes with antibiotics if infection is present, as seen in a study published in the British Journal of Anaesthesia 1, which highlights the importance of prompt management of tracheostomy-related haemorrhage to reduce mortality risk.

Common Causes

Common causes of bloody endotracheal tube secretions include traumatic intubation, suction-related trauma, coagulopathy, pulmonary infection, or underlying lung disease. The tracheobronchial mucosa is highly vascular and easily damaged, with even minor trauma potentially causing visible bleeding in secretions.

• Traumatic intubation
• Suction-related trauma
• Coagulopathy
• Pulmonary infection
• Underlying lung disease, as noted in the study published in the British Journal of Anaesthesia 1, which emphasizes the need for careful management of tracheostomy-related complications to improve patient outcomes.

From the Research

Bloody Endotracheal Tube Secretion

• Bloody endotracheal tube secretion can be a challenging issue in airway management, particularly in cases of severe bleeding in the upper airway 2.
• The use of tranexamic acid (TXA) has been studied as a potential solution for controlling bleeding in various scenarios, including bronchoscopic procedures 3, 4, 5, 6.
• In the context of endobronchial tumors, intratumoral injection of TXA has been shown to be effective in controlling significant bleeding during forceps biopsy procedures 3, 6.
• Topical infusion of TXA prior to transbronchial lung biopsies has also been found to reduce bleeding and increase the number of biopsies obtained 5.
• The management of bleeding in the airway requires a structured approach, taking into account the source of bleeding and the estimated risk of failure to intubate using direct laryngoscopy or to achieve a front-of-neck access for surgical airway rescue 2.

Techniques for Managing Bleeding

• Flexible video-/optical-scope-guided intubation via a supraglottic airway device
• Cricothyroidotomy or tracheotomy
• Retrograde-, blind nasal-, oral-digital-, light-, and ultrasound-guided intubation 2
• Intratumoral injection of TXA for control of biopsy-induced bleeding 3, 6
• Topical infusion of TXA prior to transbronchial lung biopsies 5

Outcomes and Safety

• The use of TXA has been found to be safe and effective in controlling bleeding in various scenarios, with minimal side effects 3, 4, 5, 6.
• Initial hemostatic control was achieved in 79%, 67%, and 90% of patients with surgical bleeds, medical bleeds, and multiple bleeds, respectively, in one study 4.
• The occurrence of venous thromboembolism (VTE) and seizures was relatively low and similar among patient bleeding groups 4.