PMC7160734_01
(a) Bronchoscopic findings showing polyp-like lesion on the left main bronchus about 2 cm from the carina. (b) Blood clots proximal to the polyp-like lesion suggestive of active bleeding site.
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Bedside bronchoscopy localized the lesion on the left lung with polyp-like lesion versus an abnormal vessel on the left main bronchus about 2 cm from the carina (Figure 1(a)). Blood clots were also noted proximal to the polyp-like lesion suggestive of the primary site of active bleeding (Figure 1(b)).
(a) Selective right bronchial artery angiography showed collateral flow from the right bronchial artery to the left bronchial artery supplying the presumed bronchial polyp or abnormal blood vessel (white arrow). (b) Selective left bronchial artery angiography showing left arterial supply to the lesion with collateral flow from right bronchial artery feeding presumed polyp-like lesion or abnormal vessel (white arrow).
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Bronchial artery angiography showed collateral flow from the right bronchial artery to the left bronchial artery supplying the presumed bronchial polyp or abnormal blood vessel (Figures 2(a) and 2(b)).
(a) Bronchial airway obstruction from blood clots. (b) Manually retrieved blood clots from large airway via forceps extraction.
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Multiple bleeding ensued which required fourteen (14) bronchoscopic clearings of airway blood clots via forceps extractions (Figures 3(a) and 3(b)).
(a) Chest X-ray preprone positioning showing bilateral air space disease with patchy bilateral consolidation from massive spillage of blood from bleeding left bronchial varix and atelectasis. Bilateral pneumothoraxes with placement of bilateral chest tubes. (b) Forty-eight (48) hours post prone positioning with mechanical clot extraction showed interval improvement of airspace disease.
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Pulmonary consolidations on bilateral lungs also developed which were considered to be pulmonary infarctions and/or atelectasis from plugging of airways with blood clots (Figure 4(a)). Increased positive expiratory pressure (PEEP) in the ventilator also led bilateral pneumothorax requiring bilateral chest tube placement (Figure 4(a)). The patient's oxygenation improved 48 hours post prone positioning with an interval decrease in airspace opacities on repeat chest X-ray (Figure 4(b)).