Airway Obstruction Arising From Blood Clot: Three Reports and a Review of the Literature

doi:10.1378/chest.115.1.293

Chest

Volume 115, Issue 1, January 1999, Pages 293-300

https://doi.org/10.1378/chest.115.1.293 Get rights and content

Airway obstruction due to presence of blood clot occurs in a variety of clinical settings; however, it is not always preceded by hemoptysis. The impact on respiratory function may be minimal or result in life-threatening ventilatory impairment. Three illustrative cases and a comprehensive literature review are presented. The presence of endobronchial blood clot is suggested by the clinical and radiographic findings of focal airway obstruction. The diagnosis is established by direct endoscopic evaluation. Initial efforts at removal of the airway clot, if warranted, involve lavage, suctioning, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, Fogarty catheter dislodgment of the clot, and topical thrombolytic agents.

Section snippets

Case 1

A 53-year-old man underwent re-induction chemotherapy 1 month previously for acute myelogenous leukemia. His hospital course was complicated by pancytopenia and subsequent right middle and lower lobe pneumonia. The patient remained febrile and ventilator-dependent 1 week after intubation for hypoxemic respiratory failure.

At this point, several acute respiratory events arose, each lasting approximately 1 to 2 min. These events were characterized by peak inspiratory pressures to 90 cm H₂O,

Case 2

A 54-year-old woman presented to a regional hospital with fever, cough, and right pleuritic chest pain. The chest radiograph confirmed a right lower lobe infiltrate and associated pleural effusion, consistent with community-acquired pneumonia. A thoracentesis was attempted but was unsuccessful. Further attempts resulted in massive hemoptysis (approximately 600 to 700 mL) and respiratory distress requiring endotracheal intubation.

On transfer to our hospital, a chest radiograph was notable for

Case 3

A 33-year-old man was admitted to the ICU with impending respiratory failure. Over the previous 3 days, he had developed a nonproductive cough and fever. A chest radiograph showed diffuse interstitial infiltrates. He was intubated and placed on mechanical ventilation due to hypoxic respiratory failure.

Using transbronchial biopsies, a bronchoscopy of the right lower lobe was performed. After the third biopsy was completed, copious bleeding was noted from the right lower lobe bronchus. The rate

Discussion

Acute endobronchial obstruction can develop from a variety of conditions, including bronchospasm, mucosal edema, mucous impaction, and aspirated foreign bodies. In mechanically ventilated patients, kinked or malpositioned endotracheal tubes and overinflated cuffs can also produce obstruction.1, 2

Several reports in the early medical literature described atelectasis following episodes of hemoptysis.³ The first confirmed case of endobronchial obstruction from blood clot was reported by Wilson in

References (27)

J Skatrud et al.
Blood clot cast following hemoptysis and resulting in atelectasis
Chest
(1976)
Z Vajo et al.
Endobronchial thrombolysis with streptokinase for airway obstruction due to blood clots
Mayo Clin Proc
(1996)
SL Maxwell et al.
Endobronchial streptokinase for relief of tracheobronchial obstruction by blood clots
Chest
(1992)
DB Thomson
Endobronchial streptokinase to dissolve a right mainstem clot
Chest
(1986)
W Botnick et al.
Endobronchial urokinase for dissolution of massive clot following transbronchial biopsy
Chest
(1994)
J Sprung et al.
Endotracheal tube and tracheobronchial obstruction as causes of hypoventilation with high inspiratory pressures
Chest
(1994)
JM Stanislas et al.
Intermittent airway obstruction by a floppy blood clot
Injury
(1996)
ME Kruczek et al.
Blood clot resulting in ball-valve obstruction in the airway
Crit Care Med
(1982)
D Lin et al.
Insidious onset of airway obstruction of an endotracheal tube by blood-mucus plugs
Anaesth Sinica
(1989)
J Mindline
Massive collapse of the lung complicating hemoptysis
BMJ
(1935)

JL Wilson

Hemoptysis in tuberculosis followed by massive pulmonary atelectasis

Am Rev Tuberc

(1929)

RP Allen et al.

Emergency airway clot removal in acute hemorrhagic respiratory failure

Crit Care Med

(1987)

H Hennell

Massive pulmonary atelectasis

Arch Intern Med

(1929)

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Massive hemoptysis during pregnancy is very rare. Dieulafoy's disease is one of the causes of massive hemoptysis. There are few reports of ECMO use to treat massive hemoptysis during pregnancy.
We report for the first time a patient with Dieulafoy's disease diagnosed at 29 weeks of pregnancy. The patient's hemoptysis occurred rapidly with large volumes. The bleeding amount reached 500 ml within half an hour, with the development of asphyxia and respiratory and cardiac arrest due to a blood clot blocking the airway. After successful cardiopulmonary resuscitation, the ventilator could not maintain effective ventilation. Emergency establishment of VV-ECMO was performed to maintain oxygen, and hemostasis was successfully achieved by performing bronchial artery embolization twice. We successfully cleaned blood clots in the airway four times by freezing and using a foreign body retrieval basket with an electronic bronchoscope. At the same time, small and smooth nodular lesions were found under bronchoscopy, and blood vessels with a diameter of 1.5 mm were found under Doppler mode with an ultrasonic bronchoscope, which was consistent with a diagnosis of Dieulafoy's disease. VV-ECMO was successfully stopped on the 3rd day of the disease course, tracheal intubation was successfully removed on the 5th day of the disease course, and the patient was discharged with no complications on the 16th day of the disease course.
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Citation Excerpt :
Hemoptysis is a presenting feature in most cases but the diagnosis can be challenging in up to 30% of the cases where it is absent. This is commonly seen in patients on prolonged mechanical ventilation [4–6]. On physical examination, patients present with clinical evidence of atelectasis with decreased breath sounds on the affected side and sometimes a localized wheeze can be heard.
Central airway obstruction, a frequently encountered emergency, is usually associated with blood clots, tumors, foreign bodies or mucus plugs. Airway obstruction due to blood clots can be seen as a complication of lung malignancies, infections, bronchiectasis, arteriovenous malformations or pulmonary infarction. In patients with long standing blood clots, the thrombus gets organized and firmly adherent to the airway. The diagnosis is often misleading as these clots mimic tumors clinically and on imaging. Hemoptysis is the most common presenting symptom though many patients can be asymptomatic. Direct visualization with bronchoscopy is required to establish a diagnosis. Life-threatening respiratory impairment is an indication for emergent clot retrieval. Management of these blood clots, especially when organized, is challenging. Initial attempts at removal should include suctioning, lavage or forceps extraction. When unsuccessful, further management options include balloon catheter dislodgement, use of topical thrombolytics, rigid bronchoscopy and cryoextraction.
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Chest

Selected ReportsAirway Obstruction Arising From Blood Clot: Three Reports and a Review of the Literature

Section snippets

Case 1

Case 2

Case 3

Discussion

Chest

Mayo Clin Proc

Chest

Chest

Chest

Chest

Injury

Blood clot resulting in ball-valve obstruction in the airway

Crit Care Med

Insidious onset of airway obstruction of an endotracheal tube by blood-mucus plugs

Anaesth Sinica

Massive collapse of the lung complicating hemoptysis

BMJ

Hemoptysis in tuberculosis followed by massive pulmonary atelectasis

Am Rev Tuberc

Emergency airway clot removal in acute hemorrhagic respiratory failure

Crit Care Med

Massive pulmonary atelectasis

Arch Intern Med

Selected Reports
Airway Obstruction Arising From Blood Clot: Three Reports and a Review of the Literature