Danika Evans
Hennepin County Medical Center
Minneapolis, Minnesota
Disclosure information not submitted.
Kenneth Dodd, MD
Physician
Hennepin County Medical Center
Minneapolis, Minnesota
Disclosure information not submitted.
Title: Vacuum Extraction of an Obstructing Clot in Massive Pulmonary Hemorrhage Using a Meconium Aspirator
Case Report Body
Introduction: Massive hemoptysis can cause life-threatening ventilation obstruction, especially if clots form in the trachea. These can be managed like an obstructing food bolus with bronchoscopy suction, basket retrieval, or removal via Magill forceps. In this case, we describe vacuum extraction with a meconium aspirator to relieve complete airway obstruction.
Description: A 53 year-old male with tricuspid endocarditis and septic pulmonary emboli was intubated for respiratory failure. On day two he developed blood-streaked secretions that progressed to frank blood with clots. He began to desaturate and exhibit high peak pressures on volume cycled mechanical ventilation, with exhaled tidal volumes of 50 mL. Bag-valve-mask ventilation was started, but manual breaths required significant force. Attempts to pass a suction catheter down the endotracheal tube (ETT) were unsuccessful. Bronchoscopy revealed a clot obstructing the lumen of the ETT. The patient was rapidly extubated and re-intubated by the ICU team. However, the clot did not come out with the ETT. Significant resistance to manual ventilation remained. The bronchoscope was re-introduced and a large clot was visualized overlying the carina and intermittently protruding into the ETT causing complete obstruction in a ball-valve manner. A meconium aspirator was attached to the ETT and connected to wall suction. Suction was engaged by occluding the side hold of the meconium aspirator and the clot was removed with the ETT en bloc. The patient was intubated again, and bag-valve-mask ventilation was easily performed. Repeat bronchoscopy demonstrated non-occlusive clot at the carina originating from an occluded right upper lobe bronchus; there was no ongoing bleeding. The patient went to IR for selective right sided bronchial artery embolization. The remaining clot was subsequently removed from the right mainstem via bronchoscopy with cryotherapy.
Discussion: Vacuum extraction of an occlusive airway clot using a meconium aspirator attached to an ETT proved to be quick, safe, and effective in reversing complete airway obstruction. This technique has previously been described to successfully remove obstructing food boluses, thick emesis, and copious airway secretions. To our knowledge, there are no reports of this technique being used in an adult intensive care unit.