A 34-year-old patient weighing 60 kg and 162 cm in height at 28 2/7 weeks gestation with a history of hemoptysis for 3 days and dyspnea for 2 days was transferred to our care 10 hours after emergency tracheotomy at a local hospital. The patient reported a past history of hemoptysis 20 years earlier, which had resolved without treatment. Three days prior to admission, the patient had a spontaneous occurrence of hemoptysis, with loss of approximately 10-20 mL of bright-red blood. The following day (2 days prior to admission), the hemoptysis increased to 100 mL and was accompanied by cyanosis (blue lips), which prompted the patient to visit the local hospital. Computed tomography (CT) of the lungs at that time revealed an infiltrative shadow in the left upper lung. After initial hemostasis and phentolamine treatment, hemoptysis recurred 6 hours after admission and was accompanied by markedly decreased oxygenation -radial artery blood gas analysis revealed an oxygen partial pressure (PO2) of 42 mmHg. An emergency endotracheal intubation was performed, and negative pressure suction was applied to assist ventilation, with maintenance of arterial oxygen saturation (SaO2) at approximately 95%. Subsequently, a tracheotomy was performed, and the patient was transferred by ambulance to our hospital.
On admission, the patient was conscious and had a transcutaneous oxygen saturation (SpO2) of 95%. She was scheduled to undergo a CT pulmonary angiogram; however, the hemoptysis increased significantly, preventing the examination. A lung CT scan was done instead and showed large infiltrating shadows in both lungs. After admission to the intensive care unit, the patient coughed up a large amount of pink blood and demonstrated obvious symptoms of airway obstruction. The ventilator parameters were then set to a tidal volume 350 mL, respiratory rate 20 breaths/min, positive end-expiratory pressure (PEEP) 5 cmH2O, inspiratory time 1.0 s, oxygen concentration 100%, and the actual delivered tidal volume 125 mL. Fiberoptic bronchoscopy revealed the trachea and main bronchi to be completely blocked by blood clots (Figure 1). Blood gas analysis showed PO2 50 mmHg, partial pressure of carbon oxide (PCO2) 76 mmHg, and pH 7.102. At the same time, the fetal heart rate decreased, from 150 beats/min to 50-60 beats/min. Obstetrician consultation suggested urgent correction of hypoxia and fetal heart rate monitoring. Multidisciplinary consultation with Thoracic Surgery, Respiratory Medicine, and Interventional Radiology suggested management with bronchial artery embolization performed with VV-ECMO support.
A 17 French ECMO catheter (Duraflo, Edwards Lifesciences; Irvine, CA, USA) was inserted via the right internal jugular vein, between the superior vena cava and right atrium; a 19 French catheter was inserted into the femoral vein and advanced under B-mode ultrasound guidance. Then, both catheters were connected to their respective ECMO sheath. The ECMO was set to a flow rate of 4.0 L/min, with a pump speed of 3000 r/min and return pressure of 120 mmHg. Following the establishment of VV-ECMO, radial artery blood gas showed pH 7.35, PO2 389 mmHg, PCO2 34 mmHg, and SaO2 100%, and the fetal heart rate increased to 120 beats/min.
Prior to transfer to the operating room for embolization, hemoptysis resumed. As the airway became completely obstructed, the tidal volume fell to 50 mL, and SpO2 decreased to 60%. Midazolam (0.15mg/kg) and continuous remifentanil (0.1 microg/kg/min) were administered for analgesia and sedation and vecuronium (0.1 mg/kg injected intermittently) for neuromuscular block. Following this, the PO2 rose to 88%, and the patient was immediately brought to the operating room for embolization. Embolization, with microcoils and gelatin sponge particles (350-560 microm; Hangzhou Alekang), was then performed (Figure 2), and the patient was transferred back to the intensive care unit, where a repeat fiberoptic bronchoscopy showed complete airway obstruction. Repeated irrigation and aspiration were performed, yielding only a small amount of clot. An emergency bedside carbon dioxide cryo-thrombectomy (Kooland 300 Flexible Cryoprobe, Beijing Kulan Medical Treatment Equipment Co., Ltd.; Beijing, China) was performed under fiberoptic bronchoscopy (Olympus bf-260; Germany). Endotracheal cryotherapy was repeated (for a total three times) until bronchoscopic evaluation confirmed no obstruction of the trachea and no active bleeding in the airway (Figure 3).
At 24 hours on ECMO, heparin anticoagulation was confirmed with the finding of activated partial thromboplastin time (aPTT) 55-60 seconds. However, on day 4 of admission, the fetal heart sounds abruptly stopped, and fetal monitoring confirmed an absent heartbeat. The obstetrician diagnosed stillbirth and suggested cesarean section once the patient stabilized. On day 6, only a small exudative shadow was seen in the right lower lung on bedside chest X-ray. On day 7, oxygenation was stopped for 2 hours, and the heart rate, blood pressure, and SpO2 remained unchanged, and blood gas analysis showed pH 7.36, PO2 86 mmHg, and PCO2 38.2 mmHg. Routine lower extremity vascular ultrasound on this day revealed intramuscular venous thrombosis in both lower limbs, and this prompted weaning from ECMO. On day 9 of admission, the cesarean section was performed. On day 11, bronchoscopy confirmed no obstruction in the trachea or in either main bronchi; CT pulmonary angiogram showed little inflammation bilaterally and no obstruction of the pulmonary artery or its branches. On day 15, after a successful spontaneous breathing trial, the patient was extubated, and oxygen therapy via tracheotomy was commenced. On day 17, the tracheotomy was closed and replaced by nasal oxygen inhalation. Finally, on day 20, the patient was discharged from hospital. At 3-month follow-up, there was no hemoptysis, and a few cord-shaped shadows remained in the left upper lung on CT scan (Figure 4).
Computed tomography of the lung showed a few cords in the left upper lung.