How to control massive hemorrhage during bronchoscopy (Bronchoalveolar Lavage)

From the Guidelines

To control massive hemorrhage during bronchoscopy, immediate action is essential with a systematic approach, prioritizing securing the airway with a single-lumen endotracheal tube and using bronchoscopy to identify the source of bleeding, followed by endobronchial management options such as argon plasma coagulation, Nd:YAG laser, and electrocautery for visible central airway lesions, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.

Initial Management

When managing massive hemorrhage during bronchoscopy, the initial steps are crucial for preventing further complications. This includes:

• Positioning the patient with the bleeding side down to prevent blood from flowing into the unaffected lung
• Maintaining the bronchoscope at the bleeding site while applying continuous suction to clear the airway and improve visualization
• Instilling cold saline (10-20 mL aliquots) at the bleeding site, which causes vasoconstriction and can help control hemorrhage
• Administering topical vasoconstrictors such as epinephrine (1:10,000 solution, 1-2 mL) or tranexamic acid (500 mg) directly to the bleeding site

Persistent Bleeding Management

For persistent bleeding, consider:

• Endobronchial tamponade using the bronchoscope itself, a Fogarty balloon catheter, or specialized bronchial blockers to apply direct pressure
• Intravenous tranexamic acid (1g over 10 minutes) can be administered systemically to promote clotting
• If these measures fail, protect the airway by intubating with a large endotracheal tube to facilitate ongoing suctioning and ventilation
• Severe uncontrolled bleeding may require rigid bronchoscopy for better suction capability and airway control, or interventional radiology for bronchial artery embolization, as supported by recent guidelines 1

Interventional Radiology

Bronchial artery embolization is a recommended treatment for massive hemoptysis, especially in clinically unstable patients 1, and its use is increasingly becoming the treatment of choice in recurrent hemoptysis, with the exception of infectious causes such as in cystic fibrosis 1.

Key Recommendations

• Securing the airway with a single-lumen endotracheal tube is recommended for patients with large volume hemoptysis 1
• Bronchial artery embolization is recommended for massive hemoptysis, especially in clinically unstable patients 1
• CT with contrast or CTA with contrast is recommended for imaging in massive hemoptysis 1

From the Research

Methods for Controlling Massive Hemorrhage

• Instillation of cold epinephrine-saline solution (1:10,000-100,000) through fiberoptic bronchoscopy, as seen in a study from 2, which achieved control of bleeding in 7 consecutive patients with acute endobronchial bleeding.
• Wedging the rigid bronchoscope into the hemorrhaging bronchus, tamponading the bleeding site with a balloon-tipped vascular catheter, removing the bronchoscope and intubating with a double-lumen tube, and undertaking emergency definitive surgery, as suggested by 3.
• Application of liquids, such as cold saline, vasoconstrictor agents (adrenaline, vasopressin analogues, phenylephrine, and xylometazoline hydrochloride), and tranexamic acid, which inhibits fibrin degradation, as discussed in 4.
• Use of tranexamic acid (TA), a synthetic anti-fibrinolytic agent, administered either as a bolus through the bronchoscope or via inhalation, as shown to be effective in controlling severe hemoptysis in a study from 5.
• Endobronchial balloon catheter tamponade using a parallel technique, where biopsy forceps introduced through a bronchoscope channel is used to grasp a balloon catheter, as described in 6.

Key Considerations

• Cardiorespiratory function must be maintained by modification of mechanical ventilation and drug therapy owing to the patient's condition, as noted in 2.
• The management of endobronchial bleeding usually depends on two main mechanisms: vasoconstriction and enhancing coagulation to form fibrin clots, as discussed in 4.
• There is limited data on the efficacy, dose, frequency, and safety of various agents used to control bleeding during bronchoscopy, highlighting the need for further clinical studies, as mentioned in 4 and 5.