Jill Irby

Madiha Syed

BMC Research Notes

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Syed and Irby  BMC Res Notes  (2015) 8:346 
DOI 10.1186/s13104-015-1313-7
CASE REPORT
Airway management of ruptured 
pulmonary artery “Rasmussen” aneurysm 
and massive hemoptysis
Madiha Syed* and Jill Irby
Abstract 
Background: Pulmonary tuberculosis is caused by Mycobacterium tuberculosis and its manifestations may include 
parenchymal, airway, vascular, pleural, mediastinal and chest wall lesions. Hemoptysis is a common complication of 
the disease. Massive hemoptysis occurs in about 8 % of cases; with associated mortality ranging from 5 to 25 % Mas-
sive hemoptysis secondary to pulmonary artery aneurysm rupture is a rare phenomenon presenting unique chal-
lenges in airway management and stabilization of oxygenation, ventilation and blood pressure.
Case history: We present a case of a patient with necrotizing pulmonary tuberculosis complicated by a ruptured 
pulmonary artery “Rasmussen” aneurysm requiring emergent intubation and embolization.
Conclusion: Massive hemoptysis should be treated as a medical emergency requiring the coordinated care of multi-
ple specialists including intensivists, interventional radiologists, anesthesiologists, and surgeons. Airway management 
and stabilization of cardiorespiratory status should be the highest priority, followed by timely diagnostic procedures 
to localize the site and cause of the bleeding.
Keywords: Tuberculosis, Massive hemoptysis, Airway management
© 2015 Syed and Irby. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License 
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, 
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, 
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Background
Pulmonary tuberculosis is caused by Mycobacterium 
tuberculosis and its manifestations may include paren-
chymal, airway, vascular, pleural, mediastinal and chest 
wall lesions. Hemoptysis is a common complication of 
the disease. Massive hemoptysis occurs in about 8  % of 
cases, with associated mortality ranging from 5 to 25 % 
[1]. Most of the cases of hemoptysis originate from 
hypertrophied bronchial arteries; a few cases arise from 
pulmonary artery aneurysms which arise secondary to 
focal weakening of the artery wall from inflammatory 
infiltrates [2, 3].
Case report
A 35  year African American female presented to the 
emergency room (ER) with history hemoptysis, fever 
and dyspnea. She had no significant past medical history. 
Her past surgical history was significant for hysterec-
tomy, tubal ligation and ankle surgery. Social history was 
significant for smoking 1.5  packs/day and occasional 
marijuana use. On clinical exam she was febrile (102 °F), 
tachycardic (heart rate 122  beats/min), blood pressure 
108/71, respiratory rate 22 per min and SPO2 100 % on 
room air. Laboratory evaluation was significant for ane-
mia (Hb 7.8  g/dL; Hct 26.8  %), hyponatremia with Na 
of 125  meq/L, and metabolic acidosis with bicarbonate 
of 19  meq/L. Chest X-ray showed bilateral upper lobe 
necrotizing pneumonia and a left lower lobe infiltrate.
She was evaluated with flexible bronchoscopy, which 
revealed blood trickling from the left main stem, and 
bronchoalveolar lavage which was positive for acid fast 
bacilli. She was started on rifampin, isoniazid, pyrazina-
mide, and ethambutol. CT angiogram was negative for 
any bleeding and showed bilateral cavitary lesions (the 
largest lesions were on the left, measuring 6.6 × 6.4 cm).
On hospital day 3, the patient developed massive hem-
optysis. Her hemoglobin dropped from 8 to 6.8 g/dL and 
Open Access
*Correspondence:  madihasyed85@gmail.com 
University of Arkansas for Medical Sciences, 4301 West Markham Street, 
Slot 515, Little Rock, AR 72205, USA
Page 2 of 4Syed and Irby  BMC Res Notes  (2015) 8:346 
she lost greater than 500 mL of blood within 5–10 min. 
Vital signs at that time were: temperature 99.1  °F, heart 
rate 110–120 beats/min, respiratory rate 30–40 breaths/
min, blood pressure 90–98/57–66 mmHg and SpO2 97 % 
on room air. Primary medical team contacted the anes-
thesia team for emergent intubation in the step-down 
unit. In light of the massive hemoptysis and challenges 
of securing an airway obscured by blood, the decision 
was made to take patient to the operating room for 
resuscitation and intubation. In the operating room the 
patient was pre-oxygenated with 100  % FiO2 in the sit-
ting position and a rapid sequence induction with cri-
coid pressure was performed with etomidate 20  mg IV 
and succinylcholine 100  mg IV. A videolaryngoscope 
was used to attempt to place a 35 French left side dou-
ble lumen tube. The glottis view was initially obscured 
by fresh blood. After suctioning, a Grade I view was 
obtained. An attempt was made to place a 35 French left 
sided double lumen tube, this was not successful due to 
fresh blood obscuring the view and resistance to passage 
of the double lumen tube. This was immediately followed 
by direct laryngoscopy and placement of a 7.5 sin-
gle lumen endotracheal tube (ETT). A large amount of 
blood was noted in the oropharynx and ETT tube during 
and after intubation. Blood was also noted in expiratory 
circuit and end tidal CO2 line and these were exchanged 
for fresh circuits. The patient became severely brady-
cardic after intubation (HR 30–40 beats/min) requiring 
atropine 0.4 mg and epinephrine 0.5 mg. Two 14 gauge 
intravenous lines were placed in right and left external 
jugular veins and connected to high flow fluid infus-
ers. A radial arterial line was placed. The patient was 
transfused with six units of packed red cells, two units 
of fresh frozen plasma and two units of platelets. Dur-
ing resuscitation, the patient was manually ventilated 
at a rate of 30  breaths/min, with the airway pressure 
release valve closed. Tidal volumes of only 150–200 mL 
were achieved. After stabilization of vital signs, the sin-
gle lumen tube was exchanged for a 35 French left dou-
ble lumen tube with a 14 French Cook Airway Exchange 
catheter and patient was transported to interventional 
radiology suite for embolization.
Prior to the start of the embolization, we attempted to 
ascertain position of double lumen tube with a flexible 
bronchoscope but were unable to visualize landmarks 
secondary to hemoptysis. Fluoroscopy was utilized to 
position tube and an attempt was made to isolate the 
left lung. The patient did not tolerate lung deflation with 
tidal volumes deceasing to 70 mL and absence of breath 
sounds bilaterally. The interventional radiologist iden-
tified three pseudoaneurysms in the left upper lobe of 
which two had ruptured. All three were embolized with 
NBCA (N-butyly-2-cyanoacrylate) glue. She received 2 
more liters of normal saline and intermittent boluses of 
phenylephrine during the procedure. After the proce-
dure, the double lumen tube was exchanged for a single 
lumen tube with a Cook Airway exchange catheter; she 
was sedated with midazolam 2  mg and transported to 
MICU.
The patient required ventilator support for 4  days 
after which she was extubated and given oxygen via a 
50  % Venti mask. Her post-extubation hospital course 
was complicated by delirium which improved and she 
was discharged to home with oxygen on hospital day 15. 
Arterial blood gases during the procedure and hospital 
admission are in Table 1.
Written consent was obtained from patient to pub-
lish details of the case. Case report was prepared with 
according to the guidelines in the CARE checklist (Addi-
tional File 1).
Discussion
The most common manifestations of tuberculosis tend to 
be pulmonary although virtually any organ system may 
be affected. Our patient presented with a combination 
of necrotizing pneumonia, bilateral cavitary lesions and 
Rasmussen pseudoaneurysms. Vascular complications 
may involve both the arterial and venous circulation. 
Bronchial arteries may become hypertrophied especially 
in areas of bronchiectasis, the mediastinum, and central 
Table 1 Arterial blood gases during procedure and hospital admission
Location Day Time FiO2 pH PCO2 PO2 HCO3 BE Hb/Hct SpO2 Lactate
OR 1 0133 1.0 6.94 88 117 18.9 −13.6 9.4/28 96.3 1.9
OR 1 0302 1.0 7.11 63 298 20 −9.7 10.6/32 96.9 0.6
ICU 1 0523 1.0 7.13 54 89 18 −11.4 13.6/41 93.9 –
ICU 1 0731 0.6 7.22 44 65 18 −9.4 11.6/35 91.1 –
ICU 1 2100 1.0 7.35 36 230 19.9 −5.2 8.8/26 96.6 –
ICU 4 0315 0.4 7.45 38 96 26.4 2.3 8.4/25
Floor bed 11 0.21 (room air) 7.48 42 48 31.3 7.1 7.8/23 81.7 –
Page 3 of 4Syed and Irby  BMC Res Notes  (2015) 8:346 
airway and may appear as nodular or tubular structures 
on high resolution CT. Care must be exercised by bron-
choscopist to avoid biopsying these lesions [4].
Rasmussen aneurysms are rare phenomena. These 
aneurysms arise from segmental pulmonary arteries, and 
occur secondary to infiltration of granulation tissue into 
the adventia and media. This is replaced in time by fibrin 
leading to thinning of the vessel wall and subsequent 
aneurysm formation and rupture leading to hemopty-
sis [5]. A study reviewing autopsy findings in patients 
with chronic cavitary TB showed an incidence of 5  % 
[5]. Another retrospective series of 189 patients utiliz-
ing multidetector CT reported a prevalence of 6.9  % in 
patients with massive hemoptysis and TB [3].
First line investigation in patients with massive hemop-
tysis requiring intensive care is fiberoptic bronchoscopy 
followed by urgent bronchial artery embolization. In 
patients where embolization fails emergent surgery is the 
second line option [6]. Postoperative complications may 
occur in 50  % of cases and fatality rate may be high as 
20 %, especially in cases where surgery is performed 24 h 
after onset of hemoptysis [6].
Massive hemoptysis presents a very challenging scenario 
in critical care medicine. The first priority is to gain control 
of airway and ensure oxygenation and ventilation. Intuba-
tion with a single lumen tube is recommended [7]. A double 
lumen tube may be used to get rapid control and isolation 
of the lungs if the laterality of the bleeding is known. An 
alternative to a double lumen tube could be placement of 
a single lumen tube, which can be advanced into the main-
stem bronchus on the affected side. The choice of tube 
should be dictated by the ease with which clots and blood 
can be removed from the airway as death from hemoptysis 
occurs not from exsanguination but from asphyxia which 
is caused by retained blood clots [7]. Following intubation, 
identifying and treating the cause of hemoptysis should be 
the next step. Flexible or rigid bronchoscopy to identify the 
site of the bleeding should be done. Rigid bronchoscopy 
may be advantageous in removing clots but is not good 
for visualizing peripheral lesions and requires special-
ized expertise. Flexible bronchoscopy is easily performed 
as a bedside procedure. The overall diagnostic accuracy 
of fiberoptic bronchoscopy in patients with hemoptysis is 
10–43 %, and ranges from 0 to 31 % in patients with hem-
optysis and normal chest radiographs [1]. In a study by 
Düpree et  al. repeated instillation of cold saline with epi-
nephrine (1:10,000–100,000) by fiberoptic bronchoscopy in 
intubated patients with massive hemoptysis was successful 
in 6 out of 7 patients [8]. Recognizing the dual blood sup-
ply of the lungs, selective bronchial arteriography should 
be considered to distinguish bronchial lesions from pulmo-
nary artery lesions like Rasmussen aneurysms. Bronchial 
artery lesions are responsible for massive hemoptysis in 
approximately 90 % of cases. CT scans and CXR are also 
important diagnostic tools and are usually performed prior 
to bronchoscopy. CT scans may be able to identify the 
source of hemorrhage in 63–100 % patients with hemopty-
sis, which is a higher rate than fiber optic bronchoscopy [1]. 
Fiber optic bronchoscopy and CT scans together provide a 
better chance of obtaining a diagnosis.
Of note is the alarmingly high mortality rate of 50–100 % 
for conservative management of massive hemoptysis [9]. 
Mortality rates for surgery range from 7.1 to 18.2 %, but 
may increase to 40 % for emergency surgery [10].
Conclusion
Massive hemoptysis should be treated as a medical emer-
gency requiring the coordinated care of multiple special-
ists including intensivists, interventional radiologists, 
anesthesiologists, and surgeons. Airway management and 
stabilization of cardiorespiratory status should be the high-
est priority, followed by timely diagnostic procedures to 
localize the site and cause of the bleeding. Due to the high 
risk of rebleeding a definitive diagnostic and treatment 
plan is essential prior to discharging the patient home.
Consent
Written informed consent was obtained from the patient 
for publication of this Case report and any accompany-
ing images. A copy of the written consent is available for 
review by the Editor of this journal.
Authors’ contributions
MS and JI conceived of the study, and participated in its design and coordina-
tion and helped to draft the manuscript. All authors read and approved the 
final manuscript.
Acknowledgements
The authors would like to acknowledge Dr. William Brooks Gentry, M.D., for his 
guidance and support in editing this case report.
Compliance with ethical guidelines
Competing interests
The authors declare that they have no competing interests.
Received: 23 June 2014   Accepted: 3 August 2015
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Additional file
Additional file 1:  Care Checklist of information to include when writing 
a case report.
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Airway management of ruptured pulmonary artery “Rasmussen” aneurysm and massive hemoptysis

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Airway management of ruptured pulmonary artery “Rasmussen” aneurysm and massive hemoptysis

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