A rare case of bronchial hemorrhage with dapt causing life-threatening hypoxaemia

SESSION TITLE: Critical Care Case Report Posters 46 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Pulmonary hemorrhage is a life-threatening clinical condition where bleeding from the pulmonary or bronchial vessel ruptures by the higher pressure of the bronchial system. Moreover, massive pulmonary or bronchial hemorrhage requires immediate attention in the clinical setting, as mortality rates are approximately 70 percent. On the other hand, minor hemorrhage may resemble a pneumopathy with dyspnea and hypoxemia. We report an interesting case of acute hypoxemia on a ventilator due to bronchial hemorrhage with dual antiplatelet therapy (DAPT). CASE PRESENTATION: A 58-year-old man with history of HTN, DM, HFrEF 20%, STEMI s/p DES to pLAD on DAPT (aspirin and ticagrelor) for one month presented with altered mental status and hypoxemia. He was somnolent and emergently intubated in ED. On MICU arrival, he was acutely desaturating to mid-70s on FiO2 100%. Point of care ultrasound ruled out any major cause of hypoxemia: massive pulmonary embolism and pneumothorax. Physical exam: reduced air entry on bilateral lungs and scant blood in ET tube. Lab: pH 7.27, pO2 51, pCO2 53, bicarb 24, WBC 13.33, Hbg 9.2, Plt 318, Procalcitonin 2.33, CMP, LFT, and coag: unremarkable, Respiratory panel, COVID & sputum culture negative, CXR: elevated right hemidiaphragm with collapsed RUL and RML, partially aerated RLL and mild right mediastinal shift compared to postintubation CXR. Given the history of recent STEMI with DES on DAPT for 1 month and clinical hemoptysis via ET tube, he underwent emergent bronchoscopy. There was total obstruction of right bronchus intermedius with blood clots, mild erythematous mucosa on left lung, and no endobronchial nodes. After removal of clots, oxygen saturation gradually improved to 95%. He was continued on aspirin but ticagrelor was held and bridged with IV cangrelor. While on IV cangrelor, bronchoscopy was repeated. No acute bleeding from right lung was noted, and only mild inflammation with some secretions in RUL anterior segment was observed. He was extubated successfully on Day 4 after ruling out further bleeding and transitioned back to DAPT on discharge with close monitoring. DISCUSSION: The use of dual antiplatelet therapy has been shown to be effective in patients with MI after PCI for prevention of stent thrombosis. Side effects related to DAPT have been increasing. Even though percutaneous bleeding with DAPT is common, bronchial hemorrhage is one of the life-threatening conditions and it rarely occurred with DAPT; it was 0.8% in observational study of 2355 patients who underwent DES. In case series of Tomos et.al, there is no hypoxemia with regard to pulmonary hemorrhage. Given hemoptysis and life-threatening hypoxemia with acute right lung atelectasis on CXR while on ET tube, we plan to perform emergent bronchoscopy to remove blood clots, which eventually improve oxygenation. CONCLUSIONS: Our case highlights the rare cause of DAPT leading to bronchial hemorrhage. Even though this is rare, we need to make all physicians aware of its existence. Clinical awareness of bronchial hemorrhage with blood clot in the setting of acute hypoxemia is important in which emergent bronchoscopy is crucial for removal of blood clot to improve oxygenation and so to save patients’ lives. REFERENCE #1: Shee B, Anjum F, Rockoff BI. Pulmonary Hemorrhage. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538278/ REFERENCE #2: Oualim S, Elharda CA, Benzeroual D, Hattaoui ME. Pulmonary alveolar hemorrhage mimicking a pneumopathy: a rare complication of dual antiplatelet therapy for ST elevation myocardial infarction. Pan Afr Med J. 2016 Aug 11;24:308. doi: 10.11604/pamj.2016.24.308.8828. PMID: 28154663; PMCID: PMC5267874. REFERENCE #3: Tomos I, Kallieri M, Papaioannou AI, et al. Pulmonary haemorrhage in patients receiving anti-platelets- a case series and a suggested therapeutic algorithm. Respir Med Case Rep. 2022;40:101782. Published 2022 Nov 24. doi:10.1016/j.rmcr.2022.101782 DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zin Min Htet No relevant relationships by Zinobia Khan No relevant relationships by Zin Thawdar Oo No relevant relationships by Thar Sann Oo No relevant relationships by Lwin Thant No relevant relationships by Su Lwin Lwin Tun