Balancing Hemorrhage and Thrombosis: Management of Massive PE With Concurrent Massive Hemoptysis

Introduction: Hemoptysis is a challenging manifestation of pulmonary embolism (PE) for the intensivist to manage. We present a rare case of massive PE complicated by massive hemoptysis from lung cancer, successfully managed through a multidisciplinary approach involving critical care, interventional radiology (IR), cardiology, and interventional pulmonology.


Description: A 49-year-old male undergoing workup of a lung mass with suspected metastases was admitted for hypoxemic respiratory failure and hemoptysis. Imaging revealed a left lower lobe segmental PE without right heart strain, bilateral upper lobe ground glass opacities, and airway compression from a right mainstem lesion. Active bleeding precluded anticoagulation (AC); an IVC filter was planned. On hospital day 8, he developed massive hemoptysis requiring ICU transfer. He received inhaled tranexamic acid and was prepared for intubation. Bedside echocardiography revealed new RV dilation with septal flattening. Due to tachycardia and hypotension, inotropes and vasopressors were started. Thrombectomy was considered not feasible by IR as the emboli was too distal. Hemoptysis and brain metastases precluded thrombolysis. He was eligible for bronchial artery embolization (BAE), requiring intubation and bronchial blocker placement. Anticipating acute RV collapse milrinone was added to improve RV contractility and reduce afterload. Intubation and bronchial blocker placement were successful. He underwent uncomplicated IVC filter placement and BAE. The next day, AC was cautiously restarted with a no-bolus heparin infusion while the bronchial blocker was left deflated for rapid redeployment if bleeding recurred. Over subsequent days, hemodynamic and ventilatory support requirements fell, and he was extubated on ICU day 10. He later received radiation to relieve airway compression and was eventually discharged home in stable condition.


Discussion: Massive PE with hemoptysis poses conflicting management priorities. This case demonstrates bleeding control with bronchial blocker-assisted BAE, followed by cautious AC can be lifesaving. Pre-intubation RV optimization with milrinone may mitigate peri-intubation risk of RV collapse. Survival in this high-mortality scenario underscores the importance of coordinated multidisciplinary care.