Massive airway hemorrhage in severe COVID-19 and the role endotracheal tube clamping

Abstract

Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been widely used in treating patients with coronavirus disease 2019 (COVID-19) with severe respiratory failure. However, there are few reports of the successful treatment of patients with massive airway hemorrhage in severe COVID-19 during VV-ECMO treatment. Methods We analyzed the treatment process of a patient with massive airway hemorrhage in severe COVID-19, who underwent prolonged VV-ECMO treatment. Results A 59-year-old female patient was admitted to the intensive care unit after confirmed severe acute respiratory syndrome coronavirus 2 infection with severe acute respiratory distress syndrome. VV-ECMO, mechanical ventilation and prone ventilation were administered. Major airway hemorrhage occurred on day 14 of ECMO treatment; conventional management was ineffective. We provided complete VV-ECMO support, discontinued anticoagulation, disconnected the ventilator, clipped the tracheal intubation, and intervened to embolize the descending bronchial arteries. After the pulmonary pemorrhage stopped, we administered cryotherapy under bronchoscopy, low-dose urokinase locally, and bronchoalveolar lavage in the airway to clear the blood clots. The patient’s condition gradually improved; she underwent ECMO weaning and decannulation after 88 days of VV-ECMO treatment, and the membrane oxygenator was changed out four times. She was successfully discharged after 182 days in hospital. Conclusion Massive airway hemorrhage in patients with severe COVID-19 and treated with ECMO is catastrophic. It is feasible to clamp the tracheal tube with the full support of ECMO. Notably, bronchoscopy with cryotherapy is effective for removing blood clots.

Management of massive airway hemorrhage associated with extracorporeal membrane oxygenation: A retrospective case series study

“…In the four patients reported in the literature, 7,8 the shortest elapsed time before a massive airway hemorrhage occurred was 20 min after commencing ECMO treatment, and the longest was 3 days. Our patient 9 had a respiratory indication, was on VV‐ECMO for 88 days, and developed a spontaneous massive airway hemorrhage after 14 days on ECMO. Vascular endothelial injury and changes in coagulation mechanisms in patients with COVID‐19 exacerbate the risk of airway bleeding, 5 which may be one of the reasons for the spontaneous bleeding in our patient.…”

“…We optimized this method (Figure 2) for treatment, and the patient recovered and was discharged from the hospital. 9 This approach can also be used in patients with massive airway hemorrhage unassociated with ECMO but still requiring full support from ECMO. 14 Massive airway hemorrhage associated with ECMO is more common in anticoagulation overdose or bronchial artery rupture.…”

“…In our facility, a patient with severe ARDS caused by COVID‐19 had a massive airway hemorrhage during ECMO treatment. We optimized this method (Figure 2) for treatment, and the patient recovered and was discharged from the hospital 9 . This approach can also be used in patients with massive airway hemorrhage unassociated with ECMO but still requiring full support from ECMO 14 …”

“…After searching the relevant databases and conducting rigorous screening, two works of literature met the requirements and were included 7,8 . The data of four patients were reported in the two works, and we diagnosed and treated one patient 9 . Therefore, five patients were included in this study.…”

“…7,8 The data of four patients were reported in the two works, and we diagnosed and treated one patient. 9 Therefore, five patients were included in this study.…”