an 87-year - old female with a short neck ( height 155 cm , weight 54 kg ) was admitted to the hospital via the emergency room . transthoracic echocardiography showed ejection fraction 31.7% , aortic stenosis grade 4 , severe diffuse hypokinesia , systolic dysfunction of the left ventricle , and bilateral pleural effusion . 2 ) and the hemoglobin level was 10.4 g / dl . upon admission to the emergency room , intubation with a 7.0 mm plain endotracheal tube ( ett ) was performed by a physician . coronary angiography with a left mainstem coronary artery stent was performed and 2 sessions of cpr were performed during coronary angiography . after recovery from cpr , she was admitted to the intensive care unit ( icu ) . blood from the ett was observed during suction . on the 2nd day of the icu stay , immediately after the patient returned from ultrasound - guided right pleural aspiration , blood gushed out from the oral cavity and o2 saturation dropped to 27% . cardiac arrest occurred soon and cpr was initiated . at that time , a physician tried to perform endotracheal intubation with a stylet but she succeeded in performing intubation after several failures including esophageal intubation . after the first cpr , massive bleeding through the ett and from the esophagus was observed and transfusion of blood products including packed rbcs was initiated during cpr . 3 ) and the hemoglobin level was 6.4 g / dl after recovery from the second cpr . he identified bleeding at the site just proximal and left posterior to the carina , which was presumed to be from an about 18 cm depth at the oral angle . however , the visual field of fob was very poor due to profuse bleeding and advancement of the fob into the distal tracheobronchial tree could not be executed . on emergent esophagogastroduodenoscopy , laceration was observed on the anterior and lower portions of the esophagus and bleeding from the laceration was also observed . after recovery from 2 sessions of cpr , myoclonus was observed and a neurologist suspected it as sequelae of hypoxic brain damage . physicians considered that the main cause of persistent airway bleeding was bleeding in the right lung rather than the trachea and they requested oli to the anesthesiologist . when anesthesiologists arrived in the icu , cpr was in progress for 60 minutes . at 30 minutes after arrival of anesthesiologists , vital signs were as follows : blood pressure ( bp ) 90/65 mmhg , heart rate ( hr ) 73 beats / min , and o2 saturation 67% , and considering persistent bleeding and suspected airway injury caused by violent and failed intubation , there were concerns about additional airway injury when the preexisting single lumen ett was replaced with larger diameter ett or the double lumen tube ( dlt ) . in addition , because too much blood gushed out from the esophagus , it was impossible to extubate the preexisting single lumen ett due to concerns about additional asphyxia . therefore , we decided to place the bb through the preexisting single lumen ett . at first , we inserted the bb under the guidance of an fob of 3.1 mm diameter but the visual field was not properly secured due to massive bleeding . in addition , 7.5 mm diameter of the ett was not large enough to simultaneously insert the bb and the fob , due to sticky blood clot within the lumen of the ett . because we could not guide the tip of the bb under fob , we had to blindly guide the tip of the bb into position according to the results of fob by the pulmonologist . however , the left lung was blocked on auscultation , contrary to our intention when the balloon of the bb was inflated with 8 ml air . therefore , we inserted the fob to reposition the tip of the bb after suctioning the blood in the airway . at that time , the balloon of the bb compressed the site of bleeding , which was within 1 cm proximal and left posterior to the carina ( fig . bleeding was dramatically decreased and the visual field was much improved than that before the insertion of the bb . the amount of bleeding through the ett that came out by suction was greatly decreased . ten minutes after placement of the bb , vital signs were as follows : bp 125/84 mmhg , hr 97 beats / min , and o2 saturation 97% . we tried to suction the blood through the tip of the bb for confirmation of bleeding in the left lung but blood was not suctioned . to control the bleeding in the trachea , we requested consultation with thoracic surgeons but they refused to perform surgery because of unstable patient status including recent recovery after myocardial infarction , heparinization , and post - cpr state . finally , we decided to observe the patient under do not resuscitate orders and administered midazolam 5 mg for sedation . the patient maintained stable vital signs for about 1 hours with the use of an ambu bag after placement of the bb . then the patient was shifted to mechanical ventilation ( pressure controlled ventilation ) with administration of cisatracurium 10 mg , and she showed an o2 saturation of 99% . ten units of packed rbcs , 4 units of fresh frozen plasma , and 10 units of platelet concentrates were transfused from the initial cpr on the 5th day of the icu stay . however , immediately after conversion to mechanical ventilation , the patient showed seizure - like motion on light touch . about 15 minutes after conversion , systolic bp was suddenly decreased to 70 mmhg and o2 saturation was decreased to 70% . the vital signs were not improved regardless of the use of vasopressors and 100% o2 . massive bleeding through the ett was observed again , and airway pressure was suddenly increased and tidal volume was decreased . massive hemoptysis should be managed with airway protection and hemodynamic stabilization . for airway protection in hemoptysis , oli is required , but difficulties might exist according to several clinical circumstances including poor visual field due to bleeding , the size of preexisting single lumen ett , difficult airway , small airway , physician 's inexperience with airway devices , unstable vital status , and possibility of airway injury . in our case , cardiac arrest occurred and hemoptysis was managed with violent and urgent intubation using a 7.5 mm single lumen ett . because tracheal and esophageal injury caused by violent and inexperienced intubation was suspected , we had to exclude switching of the preexisting single lumen ett to a larger diameter ett or the dlt   and we selected the bb for oli . however , it was also difficult to place the bb under fob because of the poor visual field caused by profuse bleeding from the airway and esophagus . although there is no clear cutoff value of massive hemoptysis , massive hemoptysis should always be considered as a lethal condition . as shown in this case , massive bleeding from the airway and esophagus led to unstable vital signs and large amount of blood products had to be transfused due to unstable hemodynamics . massive bleeding might contribute to consequent cardiac arrest in the patient with serious underlying conditions including severe aortic stenosis and recent myocardial infarction . chest x - ray , computed tomography ( ct ) , digital subtraction angiography , and flexible / rigid bronchoscopy are necessary for diagnosis of hemoptysis . when it is not possible to identify a localized finding in the chest x - ray such as in our case ( figs . 2 and 3 ) , other diagnostic tools including bronchoscopy and ct are necessary . ct is a highly useful tool in evaluation of hemoptysis , but it has limitations in patients with unstable hemodynamics , active bleeding requiring endobronchial management , and bilateral lung abnormalities . the patient could not be shifted to the ct room because of unstable hemodynamics , resuscitation , and active bleeding . it is performed when endovascular treatment is scheduled and other diagnostic modalities have been used . rigid bronchoscopy is more efficient than fob in many aspects , including better clearing of the airway , better visualization , protecting airway patency , and maintaining ventilation . in addition , fob can confirm the site of bleeding only in 73%93% episodes of massive bleeding   and definitive diagnosis of the bleeding site in our case could not be established before placement of the bb because of massive bleeding . the bb has advantages in patients with a difficult airway , tracheostomy , unplanned oli , and mechanical ventilation after surgery . in our case , preexisting ett , ongoing airway bleeding , and suspected airway injury led to the selection of the bb for oli instead of the dlt . when the dlt can not be an option for oli , the bb can be an alternative . however , malposition of the bb occurs more often than that of the dlt . malpositioned balloon of the bb might cause spillage of blood into both lungs and consequent hypoxemia and the underlying conditions might be aggravated . malposition of the bb can cause serious events , such as ventilation problems or cardiac arrest . in addition , placement of the bb may require longer time than placement of the dlt . therefore , in the emergent situation such as massive hemoptysis , securing the airway using the bb can be time - consuming and it can impede the treatment , particularly by inexperienced physicians . in our case , malposition of the bb was suspected due to seizure - like motion on light touch , unidentified patient movement under light sedation , or movement of the bb by medical personnel during switching to mechanical ventilation . however , physicians who were not familiar with the bb might not have noticed the exact cause of the ventilation problem . when blood came out through the ett again , the possibility of malposition of the bb should have been considered . medical personnel in the icu did not check for proper positioning of the bb at regular intervals . it was thought that the patient expired due to ventilation failure and hypoxia caused by suffocation , and thereby aggravation of the underlying conditions . in our case , balloon of the bb inadvertently compressed the site of tracheal bleeding and the degree of bleeding through the ett was greatly decreased ( figs . 1 and 4 ) . therefore , we could save considerable time ( about 1 hours ) for additional steps of treatment . various therapeutic measures exist as follows : cold saline lavage , topical vasoconstrictive agents , tranexamic acid , fibrinogen / fibrin , balloon tamponade , laser photocoagulation , electrocautery , bronchial artery embolization , and surgery . however , serious medical conditions and unavailability of equipments / agents have limited the therapeutic options . especially , myocardial infarction , heparinization , and post - cpr state made us hesitant . in conclusion , tracheal bleeding very close to the carina might be temporarily controlled using the bb such as in our case . however , considering the possibility of malposition of the bb , frequent confirmation of the bb position and more definite treatment should be pursued during temporary hemostasis .
massive hemoptysis is respiratory compromise which should be managed as a life - threatening condition . in our case , 
 the bronchial blocker played a role in hemostasis of tracheal bleeding very close to the carina and prevented further spillage into the contralateral lung . 
 right - sided one - lung isolation in an 87-year - old female , who received cardiopulmonary resuscitation due to myocardial infarction , was requested due to hemoptysis . 
 right - sided bronchial bleeding was suspected on auscultation , but esophageal and tracheal bleeding due to violent intubation with a stylet was also considered . 
 we attempted one - lung isolation with the bronchial blocker . 
 the bronchial blocker was inadvertently advanced to the left mainstem bronchus , but the inflated balloon of the bronchial blocker compressed the site of bleeding , which was within 1 cm proximal and left posterior to the carina . 
 tracheal bleeding stopped , and we confirmed that hemostasis was achieved with the balloon of the bronchial blocker using a fiberoptic bronchoscope .