(243) Pressurized Hemostasis: Positive-Pressure Ventilation in Massive Hemoptysis

Introduction: Massive hemoptysis is a potential complication of right heart catheterization (RHC). Initial management involves airway protection, hemodynamic stabilization, and maintenance of oxygenation, followed by localizing and controlling the source of bleeding. In some cases, hemostasis may be achieved with positive pressure ventilation (PPV) as described here.

Description: A 68 year old woman with a history of end-stage renal disease and cirrhosis complicated by peristomal varices presented for RHC in the setting of liver-kidney transplant workup. After wedge placement of the catheter, massive hemoptysis ensued. Although hemodynamically stable, she desaturated to ~80%, and she was intubated emergently and placed on mechanical ventilation after which the bleeding stopped. Blood was noted in the oropharynx, however no blood was noted in the endotracheal tube. Bronchoscopy revealed pooled blood clots in the distal bronchi with no signs of active bleeding. There was initial concern for a pulmonary artery (PA) rupture, but given minimal blood on bronchoscopy and history of known varices, hematemesis was thought to be the cause. Subsequent imaging showed a 16mm pseudoaneurysm of the right middle lobe medial segment PA. On formal pulmonary angiography, no pseudoaneurysm was identified. Additional intraoperative cone beam imaging showed complete thrombosis of the pseudoaneurysm, and repeat bedside bronchoscopy showed no active bleeding. She was then extubated and transferred to the floor.

Discussion: Massive hemoptysis due to PA rupture is a potential life-threatening complication of RHC. Initial management includes airway protection and hemodynamic stabilization, followed by interventions to localize and control the source of bleeding. In this case, initial bronchoscopy was unable to confirm a source of bleeding, however imaging later confirmed a pulmonary source with complete thrombosis despite mechanical ventilation as the only intervention. While there is limited evidence regarding the use of PPV in promoting hemostasis, our experience suggests PPV may play a role. PPV increases airway pressure which, similar to the mechanism of tamponade, can exert a mechanical pressure on the bleeding vessel and promote hemostasis. This effect may only be temporary, so definitive treatment may be needed.