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A 52-year-old man with known diffuse bilateral bronchiectasis and chronic Pseudomonas aeruginosa colonisation is brought to the emergency department after coughing up approximately 400 mL of bright red blood over the past 3 hours. He is anxious, tachypnoeic at 28 breaths/min, and his SpO2 is 88% on room air. He has coarse crackles over both lung bases. There is no known coagulopathy.
Questions
a) What is the immediate priority in management, and why is positioning important? (2 marks)
Immediate priority is protect the airway and the uninvolved (good) lung. Bronchiectasis haemoptysis arises from hypertrophied bronchial arteries and kills by asphyxiation from blood flooding the airway, not exsanguination. Place the patient bleeding side down (good lung up) to minimise soiling of the unaffected lung, give high-flow oxygen, insert large-bore IV access, and send bloods including cross-match.
b) Outline the next four steps in emergency management. (4 marks)
- Airway control — give high-flow O2; if bleeding is torrential or airway threatened, intubate with a large-bore tube and preferentially ventilate the good lung (advance ETT to the main bronchus of the non-bleeding side or use a dual-lumen tube if skilled).
- Circulation — resuscitate with crystalloid and blood products; cross-match 4–6 units; correct coagulopathy/thrombocytopenia.
- Localise — bronchoscopy once stable enough to identify the bleeding lobe/segment.
- Definitive haemostasis — arrange urgent bronchial artery embolisation; surgical resection is reserved for embolisation failure or localised refractory disease.
c) Name two factors in this patient that predict severe bronchiectasis and a worse prognosis. (2 marks)
- Chronic Pseudomonas aeruginosa colonisation — marker of severe disease, more exacerbations, faster FEV1 decline, higher mortality.
- Diffuse bilateral disease — greater radiological extent predicts worse outcomes and is part of BSI/FACED severity scoring.
d) After the acute bleed is controlled, what two long-term measures reduce recurrence risk? (2 marks)
- Optimise airway clearance (supervised physiotherapy, possibly mucoactive agents) and treat chronic Pseudomonas — long-term inhaled antibiotic and/or macrolide if exacerbations are frequent (≥3/year). Exclude/treat NTM before macrolides.
- Vaccination (influenza, pneumococcal, COVID-19), smoking cessation if applicable, and pulmonary rehabilitation.