A Multi-Modal Approach to Life-Threatening Hemoptysis in a Patient with COVID-19 ARDS

Introduction: Life-threatening hemoptysis is rare in patients diagnosed with COVID-19. Here, we describe a severe case of hemoptysis a patient with COVID-19 and the multi-modal approach to manage this condition. Case: A 57 year-old man with diabetes was admitted with hypoxemic respiratory failure due to COVID-19 pneumonia. Despite treatment with convalescent plasma, remdesivir and dexamethasone, he developed progressive respiratory failure eventually requiring VVECMO support on hospital day 8. He was started on heparin for therapeutic anticoagulation at this time. Anticoagulation was held on day 23 after large blood clots were suctioned via tracheostomy tube. CT revealed complete opacification of the bilateral lungs and major airways without evidence of acute arterial blushing (panel A). The patient underwent the first in a series of therapeutic bronchoscopies via a size 10 Shiley tracheostomy tube on day 28. Occlusive gelatinous blood clots were noted immediately upon entering the trachea. After failure of adequate clot evaluation with cryoprobe, a modified 24F chest tube was used as a suction catheter to achieve clot removal. After visualizing major airways, a bronchial blocker was positioned in the bronchus intermedius. Topical tranexamic acid was applied to sites of bleeding in the left upper lobe. Repeat bronchoscopy was performed on day 30, which showed new bleeding in the left lower lobe segments. An endobronchial blocker was repositioned in the left lower lobe and Surgicel was applied to ongoing bleeding sites within the right and left lung. Prior to repeat bronchoscopy, the patient was administered inhaled tranexamic acid three times daily due to findings of severely inflamed mucosa and diffused nature of bleed. On day 32, bronchoscopy revealed significantly improved bleeding. In-line suctioning was held in favor of daily diagnostic bronchoscopies to avoid suction trauma. Ultimately, the patient's bleeding resolved and he was eventually liberated from both ECMO and the ventilator with corresponding improvement on CT imaging (panel B). Discussion: We describe a case of a life-threatening hemoptysis in a patient with COVID-19 ARDS who was successfully managed using serial therapeutic bronchoscopies employing cryotherapy, mechanical tamponade, and pharamacologic coagulants to achieve hemostasis.