From the Guidelines
Bleeding from the nose and throat during intubation is a significant concern, with a reported incidence of complications ranging from 20% to 50% in ICU settings, as noted in the 2017 study published in Anaesthesia 1. The risk of epistaxis and hemorrhage from the throat during endotracheal intubation is increased in certain situations, including:
- Traumatic or difficult intubations
- Multiple intubation attempts
- Use of larger endotracheal tubes
- Pre-existing coagulopathies
- Anticoagulant medication use
- Anatomical abnormalities To minimize bleeding risk, proper technique is essential, including:
- Appropriate tube sizing
- Adequate lubrication
- Gentle manipulation
- Consideration of video laryngoscopy for difficult airways For patients on blood thinners or with known bleeding disorders, temporarily adjusting medication if possible and having suction equipment readily available is advisable, as suggested by the 2001 study in Intensive Care Medicine 1. While most bleeding resolves spontaneously, persistent or severe bleeding may require intervention such as:
- Direct pressure
- Topical vasoconstrictors like oxymetazoline
- Rarely, ENT consultation The presence of blood can complicate the procedure by obscuring visualization of the airway, potentially making intubation more challenging, highlighting the importance of careful preparation and anticipation of potential complications, as emphasized in the 2017 study in Anaesthesia 1.
From the Research
Epistaxis and Hemorrhage during Endotracheal Intubation
- The likelihood of a patient experiencing epistaxis (nosebleed) and hemorrhage from the throat during endotracheal intubation is a significant concern, as uncontrolled nasal bleeding can lead to hypovolemia and airway compromise 2.
- According to a study, an estimated 60% of the population will have a nosebleed in their lifetime, and 6% will require medical intervention 2.
- In cases of massive hemoptysis, rapidly available nebulized tranexamic acid (TXA) may be considered a therapeutic option, serving either as primary therapy or as a bridge until other definitive therapies can be arranged 3.
- TXA has been used to treat pulmonary hemorrhage after tissue plasminogen activator administration for intubated patients, with successful cessation of bleeding 4.
Management of Bleeding in the Upper Airway
- Failure to manage bleeding in the airway is an important cause of airway-related death, and techniques such as flexible video-/optical-scope-guided intubation via a supraglottic airway device, cricothyroidotomy or tracheotomy, and retrograde-, blind nasal-, oral-digital-, light-, and ultrasound-guided intubation can be employed to establish a definitive airway 5.
- A structured approach to managing bleeding in the airway should account for 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 5.
- Nebulized tranexamic acid has also been used as a therapeutic alternative in patients with pulmonary hemorrhage on veno-venous ECMO, with significant stabilization of hemodynamics, reduced circuit changes, and less time off of anticoagulation 6.