Among the many emergencies that can occur while treating patients, bleeding in the airway — which can be caused by various disorders, injuries and even accidents during treatment — presents significant and unique challenges for providers navigating airway management.
An actively bleeding airway is one of the most significant predictors of intubation failure and mortality, and providers must therefore always remain vigilant in looking for factors and preexisting conditions that may contribute to airway bleeding, as well as understand management techniques for mitigating bleeding and any crises that may result from it.
Causes of airway bleeding
There are various disorders — both inherited and acquired — that result in airway bleeding for patients. Bleeding disorders are defined by an inability to form proper blood clots, and some examples of these disorders include hemophilia and Von Willebrand disease, or disorders stemming from blood-thinning medications, cirrhosis of the liver or traumatic injuries. Bleeding disorders also sometimes stem from conditions like anemia, HIV, leukemia and vitamin K deficiency.
Minor respiratory illnesses like upper respiratory infections and viral bronchitis also cause patients to cough up blood, which travels down the throat and into the airway, and can result in illnesses such as Goodpasture syndrome or granulomatosis with polyangiitis, which are linked to the inflammation of blood vessels in the lungs.
Another common cause of airway bleeding is hemoptysis, respiratory compromise with symptoms ranging from blood-tinged sputum to massive bleeding. Massive hemoptysis is a life-threatening condition that involves a large amount of blood or rapid rate of bleeding associated with an elevated risk of mortality and emergency outcomes such as airway obstruction, hypotension and pulmonary collapse.
As these many examples demonstrate, blood in the airway or active bleeding can occur in far more ways than trauma, so understanding a patient’s medical history, perhaps from a nearby family member, can help inform the full context of an emergency that includes airway bleeding.
Airway management and suctioning protocols
When responding to crises like hemoptysis and other conditions that trigger airway bleeding, it’s easy for providers to panic, especially if the bleeding is overwhelming, but knowing what suctioning and airway management techniques to employ is the best way to remain prepared for any patient scenario, and ensure you respond safely, proactively and effectively when treating life-threatening symptoms and conditions.
Establishing an airway is the most important step in the management of hemoptysis. Other vital considerations before, during and after treatment include easy access to equipment, availability of skilled operators and an efficient and organized approach to securing the airway.
ETT (endotracheal tube) intubation is the most common and accessible method of airway management when treating an actively bleeding airway, and it involves the use of instruments such as therapeutic flexible bronchoscopes and bronchial blockers, consisting of long, flexible catheters, for blood clot extractions and recovery of airway patency.
One of the most reliable techniques for suctioning blood in the airway, the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique, requires aggressive suctioning in order to fully clear the airway for intubation. There are many benefits to this technique — not the least that it increases the chances for a successful, safe intubation. When performing SALAD, providers can leave the catheter in place during intubation, providing an easy route for removing blood and other contaminants, in addition to easy access to the trachea, even during continuous bleeding.
If blood clotting occurs, it may seem wise to remove the clots as soon as they are identified, but sometimes suctioning of smaller clots can lead to re-bleeding if the clots originate in the lower airway. Larger clots must be removed from the airway since they can produce life-threatening airway obstruction and secondary complications in the lungs.
Knowing the risks
Providers must always be aware of patients’ preexisting conditions and risk factors going into treatment, in addition to remaining knowledgeable about the causes of airway bleeding, best practices for mitigating bleeding as safely and efficiently as possible, and what equipment is best for airway management.
Read this blog to learn more about the risks of hemophilia and other bleeding disorders.