Pulmonary hemorrhage.

BelgianRN · May 15, 2012

In general when we have a pulmonary hemorrhage we intubate the patient out of comfort measures. Plus the addition of PEEP to the lungs sometimes has a tamponade effect on bleeding (esp if there is diffuse hemorrhage).

Intubating them makes it possible to do a bronchoscopy and check for the source of bleeding e.g. left/right. If you can identify the side of the bleeding it's possible to insert a double lumen tube or do a selective intubation of the right/left main stem. This gives you the possibility to ventilate the unbleeding lung while you work on a way to stop the bleeding (e.g. bronchoscopic infusion of epinephrine on the site of the bleeding, leaving a blocker so the bleeding site will tamponade itself). But I admit this sounds great on paper and if you have someone there that is really skilled at airway management.

Next step in our hospital is usually angiography to see if we can find the source of the bleeding and attempt to coil it. And a last resort is naturally surgery to see if you can stop it that way.

The hypoplastic right heart complicates things of course since measures like PEEP are possibly not as well tolerated considering the patient is likely volume depleted due to bleeding. On top of that adding PEEP increases the risk of shutting down collateral circulation (as it is probably very weak pulmonary flow or passive pressure gradient collateral flow that is in the same magnitude as the PEEP values). And all depends on the patient and how well she would tolerate that (safe bet would be not really well ^^).

On patients that suffer from pulmonary hemorrhage due to a problem that isn't treatable there are usually advanced orders and comfort measures that are taken. I remember the pulmonary department of another hospital having a protocol that in case of massive hemorrhage that isn't treatable the nurses have standing orders to push a large amount of morphine and midazolam as they are notifying the MD.

umcRN, BSN, RN · May 16, 2012

Thank you for that fantastic answer!

I am sure we weren't intubating her for the exact reasons you mentioned, and she was maintaining herself, but definitely miserable. The doctors also just didn't seem as concerned as myself and the respiratory therapist which made me nervous, and as I've never been involved in an adult code I may have just been jumping the gun letting my nerves get away with me and making myself worry! haha (although I am always going to worry if someone is coughing up liters of blood!)

In any case the coughing and bleeding stopped, and today, two days later, she was gone. I don't know if they've decided to cath her or not but if they do i'm sure she'll be back afterwards.

Esme12, ASN, BSN, RN · May 16, 2012

Belgian gave you a great answer and I agree it was probably the hypoplastic R heart that cause hesitation for intubation as these patients do not tolerate the increased intrathoracic pressure. As ped nurse, seeing that amount of blood that can be lost on an adult and tolerated is staggering, when compared to the little ones. Either way coughing up blood is disturbing no matter how you look at it.

Curious....Are you working adult now? or floated.

umcRN, BSN, RN · May 17, 2012

no no! I would NEVER switch to adults :lol2: we admit adult congenital hearts to our hospital. There is an adult congenital heart program out of the adult hospital next door but they work with our (peds) docs and when the pts are admitted (or have to go to the ER) its always to our children's hospital. So we do get our share of adults up to their 50's (since apparently they're surviving that long nowadays) but many of us who have never worked adult are just not as comfortable with these patients. And it's not an every day occurrence obviously, sometimes only 2-3 a month and they are usually known to the unit since they have chronic issues re. to their heart disease and are in and out. Their common issues are renal related, arrhythmias & CHF...and sometimes valve replacements, pace makers, collateral stenting, post caths, things like that. Pulmonary hemorrhage was a new one for me, and you're right, I was impressed at the amount of blood she managed to cough up, never seen anything like that in my kiddos!

Esme12, ASN, BSN, RN · May 17, 2012

It's a lot even for us adult pros!! For My years of nursing in critical care it would UN-nerve me too!!!!

jelly221,RN, MSN · May 22, 2012

no no! I would NEVER switch to adults we admit adult congenital hearts to our hospital. There is an adult congenital heart program out of the adult hospital next door but they work with our (peds) docs and when the pts are admitted (or have to go to the ER) its always to our children's hospital. So we do get our share of adults up to their 50's (since apparently they're surviving that long nowadays) but many of us who have never worked adult are just not as comfortable with these patients. And it's not an every day occurrence obviously, sometimes only 2-3 a month and they are usually known to the unit since they have chronic issues re. to their heart disease and are in and out. Their common issues are renal related, arrhythmias & CHF...and sometimes valve replacements, pace makers, collateral stenting, post caths, things like that. Pulmonary hemorrhage was a new one for me, and you're right, I was impressed at the amount of blood she managed to cough up, never seen anything like that in my kiddos!

Whoa! Where do you work? I'm in cardiac DOU now, transferring to CVICU this summer, but I had a congenital heart kid a couple of months ago, and I was fascinated both by learning more about the repairs they do for these kids (he had a modified Fontan I think...) and because he was such a cool kid. It was very inspiring and I've always loved kids, I was an Elementary Education major until I realized I really wanted to do nursing. But seriously, your floor sounds amazing!!!