Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation

Abstract

Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. Methods: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. Results: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. Conclusions: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery.

Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway

“…Krecmerova et al [ 10 ] successfully performed massive alveolar lavage with severe alveolar proteinosis under the support of ECMO. Pitcher et al [ 11 ] successfully performed emergency surgery on patients with massive hemoptysis with ECMO support. Natt et al [ 12 ] successfully performed balloon dilatation and tracheal stenting with V-V ECMO support in patients with severe tracheal occlusion after tracheal intubation, and the patient's postoperative dyspnea was significantly restored.…”

Bronchial Occlusion with Endobronchial Watanabe Spigot for Hemoptysis in a Mechanically Ventilated Patient with Extracorporeal Circulation

“…A previous retrospective study reported that complications from massive hemoptysis occurred in 2.5% of patients on ECMO (3). The occurrence of massive hemoptysis in heparinized ECMO patients, although rare, is a serious and potentially lethal complication.…”

The intersection of bronchoscopy and extracorporeal membrane oxygenation

“…Thrombotic events (clot requiring circuit change, deep vein thrombosis, pump head failure due to clot, or pulmonary embolism) happened at a rate of 53% (16). Pitcher et al highlights how to manage hemoptysis while on ECMO (17). In a retrospective case series, 3 patients on VA-ECMO developed massive hemoptysis (defined as greater than 300 mL of blood in 24 hours) in the setting of antiplatelet therapy or a pulmonary artery catheter placement and were refractory to correction of coagulation, cold saline or epinephrine by bronchoscopy or bronchial blocker placement.…”

“…Bronchoscopy is performed afterwards for removal of clot and bronchial casts. Cryotherapy can help facilitate removal of clot from the lungs (17). Once bleeding stops, anticoagulation is resumed due to thromboembolic risk with careful monitoring of rebleeding.…”