Single-Lumen Endotracheal Intubation Combined with Dynamic Positioning for Bronchoscopy- Associated Acute Massive Airway Hemorrhage: A Case Series Based on ABCDE protocol

Single-Lumen Endotracheal Intubation Combined with Dynamic Positioning for Bronchoscopy- Associated Acute Massive Airway Hemorrhage: A Case Series Based on ABCDE protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Lumen Endotracheal Intubation Combined with Dynamic Positioning for Bronchoscopy- Associated Acute Massive Airway Hemorrhage: A Case Series Based on ABCDE protocol Mingyuan Yang, Huafeng Wei, Qinghao Cheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6598199/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Bronchoscopy-associated acute massive airway hemorrhage (BAMAH) is a life-threatening emergency requiring rapid intervention. Traditional methods face challenges in emergency settings due to operational complexity and clot occlusion risks. This study evaluates a novel ABCDE protocol guided strategy integrating single-lumen endotracheal intubation with dynamic positioning. METHODS A retrospective case series analyzed 8 AMAH patients (2004–2021) managed at a tertiary hospital. The intervention combined single-lumen tube compression hemostasis (cuff-targeted mechanical tamponade) and dynamic positioning (Trendelenburg with lateral tilt). Outcomes included hemostasis success rate, oxygenation improvement, and complications. RESULTS Hypoxemia was observed in all eight patients, with six patients exhibiting a minimum oxygen saturation of 0%, while the remaining two patients had minimum oxygen saturations of 10% and 20%, respectively. The mean duration of operation was 100 minutes (range:50min-190min), and the mean blood loss volume was 2137.5 ml (range:800ml-3600ml). All patients achieved immediate hemostasis, post-intubation SpO₂ increased to ≥90%, and no mortality occurred intraoperatively. However, 50% mortality (4/8) was observed due to disseminated intravascular coagulation and multi-organ failure. CONCLUSION The ABCDE protocol (Airway-Bleeding-Circulation-Disposal-Endotracheal intubation) provides a structured framework for managing BAMAH. Single-lumen intubation with dynamic positioning achieves dual goals: rapid hemostasis via cuff compression and lung protection through gravity-assisted drainage. TRIAL REGISTRATION: not applicable. Figures Figure 1 Figure 2 KEY POINTS Bronchoscopy associated acute massive airway hemorrhage (BAMAH) is life-threatening. There is no systematic rescue process and method, and traditional hemostasis methods are limited by their complexity. This study establishes that the ABCDE protocol-guided strategy (Airway-Bleeding-Circulation-Disposal- Endotracheal Intubation), featuring single-lumen tube compression hemostasis and dynamic positional adjustment, which achieving dual therapeutic advantages in acute massive airway hemorrhage: rapid bleeding control and lung function preservation. It enables structured management and achieves rapid hemostasis and lung protection. Meanwhile its inherent simplicity, anatomical adaptability, and multifunctional design significantly enhance emergency response efficiency and clinical outcomes. Background Bronchoscopy-associated acute massive airway hemorrhage was defined as massive hemorrhage of more than 100 ml caused by bronchoscopy intervention therapy, with rapid outflow of blood from the bleeding point, blurred vision of bronchoscopy, inability to stop bleeding quickly, and blood filling the alveoli, which seriously affects the oxygen supply function of the lung lobes( 1 ). It represents the most severe complication associated with bronchoscopy diagnosis and treatment, characterized by a low incidence rate but high mortality( 2 ). In such time-critical emergencies, clinicians face chaotic scenarios where a standardized emergency protocol and a rapid, technically simple intervention are imperative to seize the narrow 1–2 minutes window for successful resuscitation after failed conventional measures. Current management strategies prioritize pulmonary isolation and hemostasis, employing tools such as endoscopic balloon occlusion, double-lumen endotracheal tubes (DLTs), and bronchial blockers. However, these methods suffer from intrinsic limitations in emergency practical application: endoscopic balloons require concurrent use with other ventilation devices and cannot function independently; bronchial blockers and double-lumen endotracheal tubes necessitate precise positioning under bronchoscopy guidance—a time-consuming process further complicated by narrow lumens prone to clot obstruction. These limitations significantly reduce their practicality in emergency settings, highlighting the urgent need for a simpler and more efficient solution. Tracheal intubation, traditionally viewed as a tool primarily for airway ventilation, can be leveraged more flexibly in emergencies to extend its utility beyond ventilation. For instance, PVC single-lumen tracheal intubation, due to its ease of locating, can achieve lung isolation and pressure hemostasis through its cuff, demonstrating potential advantages in managing acute massive airway bleeding. Compared to endoscopic balloons and bronchial blockers ( 3 , 4 ), this approach theoretically eliminates clot occlusion risks and reduces procedural time—critical advantages in hemorrhagic crises. This study aims to explore the hemostatic effects of single-lumen endotracheal intubation with cuff compression, and validate the clinical utility of an ABCDE-based emergency protocol (Airway assessment, Bleeding stratification, Circulatory support, Disposal interventions, Endotracheal intubation) for treating acute massive airway hemorrhage. Through analysis of 8 protocol-driven cases, the necessity of standardization emergency airway management was fully demonstrated, providing a novel perspective for emergency interventions. Methods Study design and population This retrospective cohort study analyzed electronic medical records of patients who underwent bronchoscopy interventional therapy at the Respiratory Endoscopy Center of Emergency General Hospital between January 2004 and December 2021. Ethical approval for this study (Ethical Committee number: K21-39) was provided by the Ethical Committee of Emergency General Hospital, Beijing, China on 29 November 2021. All patients of Respiratory Endoscopy Center were informed that the patients' clinical data might be used in clinical studies and signed the informed consent form on admission and before bronchoscopy intervention therapy. Inclusion Criteria includes: experienced bronchoscopy-associated acute massive airway hemorrhage during the procedure and required compression hemostasis via endotracheal intubation; possessed complete perioperative records. Exclusion Criteria includes: non-acute massive hemorrhage; acute massive hemorrhage managed successfully via endoscopic balloon compression without requiring endotracheal intubation; incomplete medical records. Eight patients occurred acute massive airway hemorrhage intraoperatively and was managed through compression hemostasis via tracheal intubation. Management strategy in process of rescue and disposal Once airway bleeding occurs during the operation, it is imperative to remain calm, assess the severity of the bleeding, and select the appropriate rescue disposal method adherence to a predefined standardized protocol to ensure timely and effective intervention. The management strategies for bronchoscopy-associated acute massive airway hemorrhage differ significantly from those for non-acute massive hemorrhage. A structured ABCDE-based protocol is systematically applied, prioritizing critical evaluations of airway assessment, bleeding extent, and circulatory function. This approach ensures a seamless transition from initial assessment (A-B-C) to targeted interventions (D-E), enabling rapid stabilization and definitive hemostasis. (as shown in Fig. 1 ). ABCDE Protocol A: Airway assessment. In the diagnosis of acute massive airway hemorrhage, airway assessment is the primary and crucial step, mainly including the following three aspects: Localization of Bleeding Site: Identify the precise origin of hemorrhage (main airway, left/right main bronchus, or carina). Evaluation of Concurrent Airway Pathology: Assess structural abnormalities (e.g., stenosis, tumors, or mucosal lesions) in non-bleeding areas to ensure safe intubation and airway patency. Oxygenation and ventilation management: Continuously monitor the patient's oxygenation status (SpO₂ and arterial blood gas), adjust ventilator parameters to ensure adequate oxygen supply to the patient, and cooperate with the surgeon to complete hemostasis operations. B: Bleeding extent Assessment of bleeding extent involves evaluating three critical dimensions: speed, volume, and clinical impact, which collectively guide intervention prioritization. 1. Bleeding speed: Patients are stratified into two categories based on the bleeding speed: non-acute bleeding and acute bleeding. Non-acute bleeding: Slow hemorrhage rate allowing clear endoscopic visualization, allowing proceed with local hemostasis and bronchoscopy interventions. Acute bleeding: Rapid hemorrhage and blood rapidly fills the airway causing obscuration of endoscopic vision or even complete obscuration of anatomical landmarks, needing immediate escalation to advanced hemostatic methods. 2. Bleeding volume: As the cumulative bleeding volume increases, it not only affects alveolar oxygenation function but also impacts the systemic circulation and coagulation function. The stepwise management of acute massive airway hemorrhage prioritizes sequential interventions based on bleeding speed and volume, outlined as First-line: Endoscopic Balloon Tamponade; Second-line: Endotracheal Intubation with Hemostatic Compression; Third-line: Bronchial Artery Embolization. C: Circulation function The effects of acute massive airway hemorrhage on the circulatory system primarily encompass circulatory dysfunction due to hypoxia and reduced blood volume. These two factors synergistically exacerbate the patient's condition, necessitating prompt measures to ensure adequate blood volume and preparation of vasoactive drugs. According to the changes of blood loss and circulation capacity, appropriate rehydration, blood preparation and antishock therapy should also be performed and considered. Effects of Hypoxia on Circulatory Function: Acute massive hemorrhage results in blood backflow into the alveoli, disrupting gas exchange. This leads to a rapid decrease in blood oxygen levels (hypoxemia), causing tissue hypoxia. Hypoxia-induced cardiac dysfunction, including decreased cardiac output and myocardial ischemia, can occur early and progress rapidly, making it challenging to correct quickly. Prioritizing interventions to restore oxygen delivery, such as airway clearance and intubation, is crucial. Effects of Hypovolemia on Circulatory Function: Acute massive hemorrhage causes a rapid reduction in circulating blood volume, leading to hypovolemic shock. This reduces cardiac preload and cardiac output, resulting in inadequate tissue perfusion and potentially exacerbating multiple organ dysfunction. Compared to hypoxia-induced circulatory disturbances, hypovolemia-induced circulatory disturbances may occur later but have a significant impact on blood pressure and perfusion. Timely blood volume replacement, such as transfusion or rehydration, is essential for correcting these issues. Extracorporeal Membrane Oxygenation (ECMO): ECMO is capable of maintaining oxygenation and stabilizing circulatory function, guaranteeing the perfusion of crucial organs and providing conditions for interventional hemostasis via bronchoscopy, surgical hemostasis, and interventional vascular embolization hemostasis. Nevertheless, systemic anticoagulation is necessary for ECMO to prevent tubing thrombosis. However, during massive airway hemorrhage, anticoagulation might aggravate the bleeding. The dosage of heparin can be adjusted to the lower limit by monitoring ACT (activated clotting time) or APTT. Even for patients with an extremely high risk of bleeding, anticoagulation can be temporarily suspended. Anticoagulation management is the key to success and requires a comprehensive decision based on bleeding and coagulation status. The ultimate objective is to withdraw ECMO as early as possible after successful hemostasis to avoid complications. D: Disposal Drug hemostasis: Intravenous infusion of hemostatic drugs, coagulation factors, plasma infusion, etc. Endoscopic hemostasis: Endoscopic hemostasis involves bronchoscopy lavage of frozen saline, diluted epinephrine (1:10 000–1:10 000), thrombin into the local bronchus and thermal coagulation of the bleeding point by APC, electropuncture, electrocoagulation, laser to burn the bleeding point, and endoscopic balloon can also be used for local compression to stop bleeding. Operation position: Place the patient in the Trendelenburg position and prepare an additional negative pressure suction device to facilitate blood drainage, thereby preventing blood from flowing into the distal alveoli and compromising lung function. In cases of controllable hemorrhage, it is unnecessary to directly elevate the non-bleeding side; instead, slightly elevate the bleeding side. This positioning strategy under a gradient Trendelenburg posture minimizes blood entry into the non-bleeding lung while preserving the oxygenation capacity of the distal non-bleeding alveoli in the affected lung. In cases of uncontrollable massive hemorrhage, immediately reposition the patient to a modified Trendelenburg with lateral decubitus (bleeding lung positioned inferiorly, non-bleeding lung superiorly). This configuration prioritizes ventilation and oxygenation of the non-bleeding lung. E: Endotracheal intubation When the bleeding rate is too fast, bronchoscopy hemostasis cannot be performed because blood rapidly fills the airway, obscuring the field of view. The blood is constantly pouring out, and effective measures to stop the bleeding should be taken immediately. If the source of bleeding cannot be identified following a rapid assessment, or if the bleeding originates from a major artery, blind hemostasis is not expected to be successful. Instead, the rigid bronchoscope or flexible bronchoscope should be promptly removed, and replaced with a poly vinyl chloride (PVC) material endotracheal intubation tube (preferred size of 7.5 and 8.0). At the same time, change to Trendelenburg position with the bleeding lung down. The location of the intubation varies according to the bleeding site (shown in Fig. 2 ). If the bleeding is at the central tracheal airway beyond carina, intubate to the distal end of the bleeding site and use the capsule of the intubate to compress the bleeding. If the bleeding site is on one side of lung, the tube is cannulated to the opposite main bronchus without bleeding, and the capsule is fixed on the carina. The proper placement of the capsule on the carina can not only seal the blood extravasation from the bleeding lung, but also ensure the normal ventilation of the contralateral un-bleeding lung. The specific steps are as follows: First, quickly insert the PVC tube into non-bleeding main bronchus by an experienced anesthesiologist. Secondly, adjust and fix the capsule at the carina by experienced endoscopist under the guide of flexible bronchoscope to stop blood spilling out from the bleeding lung. Thirdly, fully attracted the blood and secretion of the non-bleeding lung. Due to the high airway pressure at this time, manual ventilation is recommended to maintain oxygenation. 15 minutes later, flexible electronic bronchoscope was inserted to check the bleeding after cuff release or to withdraw the endotracheal tube to the main airway. If airway bleeding is effectively controlled, rigid bronchoscope can be replaced to facilitate subsequent airway procedures, trying to open up some lobes or segments of the lung. If the bleeding is partially alleviated, the duration of compression can be appropriately prolonged. If hemostasis remains ineffective after multiple attempts of endotracheal intubation compression, priority should be given to sustaining the compression to provide a stable condition and additional time for subsequent surgical intervention or emergency bronchial arterial embolization. Results A total of 8 patients (5 males and 3 females, with a mean age of 57.25years) experienced severe bronchoscopy-associated acute massive airway hemorrhage. Among the eight patients, three were diagnosed with primary lung cancer, three with secondary lung cancer, and two with benign lesions, specifically aspergillosis pneumonia and polychondritis. The average degree of airway stenosis attributable to preoperative lesions was 83% (range:50%-100%), and all patients exhibited varying degrees of breath-holding symptoms preoperatively. The mean Karnofsky Performance Status (KPS) score was 63.75(range:50–90), and the mean modified Medical Research Council (mMRC) dyspnea scale score was 2.625(range:1–4). The lesions responsible for the hemorrhage were situated in the central airway (37.5%), specifically within the left or right main bronchus (62.5%). The causes of bleeding encompassed tumor tissue excision (62.5%), transbronchial lung Biopsy (TBLB) (12.5%), balloon dilatation and associated tears (12.5%), as well as spontaneous hemorrhage from the tumor (12.5%). All 8 patients ultimately underwent endotracheal intubation for compression hemostasis and one-lung ventilation. Three patients received emergency arterial embolization with the assistance of intubation compression to enhance hemostatic efficacy. Intraoperative adverse events included hypoxemia, hemorrhagic shock, and cardiac arrest. Hypoxemia was observed in all eight patients, with six patients exhibiting a minimum oxygen saturation of 0%, while the remaining two patients had minimum oxygen saturations of 10% and 20%, respectively. It is noteworthy that hemorrhagic shock occurred during the procedure, leading to cardiac arrest in five patients. Fortunately, no patient experienced intraoperative mortality, and all eight patients were safely transferred to the ICU with successful compression hemostasis achieved and one-lung ventilation through endotracheal intubation. The mean duration of operation was 100 minutes (range:50min-190min), and the mean blood loss volume was 2137.5 ml (range:800ml-3600ml). Finally, four patients succumbed to severe postoperative complications, including multiple organ failure and disseminated intravascular coagulation (DIC), within 48 hours following the procedure. Discussion Acute massive airway hemorrhage is a recently introduced concept that further categorizes the condition from the original diagnosis of massive airway hemorrhage by emphasizing its acute nature, which reflects the critical and severe state. In this study, eight cases of bronchoscope-related acute airway hemorrhage were analyzed, and an innovative emergency strategy was proposed, which integrates single-lumen endotracheal tube compression hemostasis with dynamic positional adjustment based on "ABCDE" protocol. "ABCDE" protocol encompasses airway assessment, bleeding extent, circulatory function, disposal process, and endotracheal intubation. By closely integrating with clinical practice and leveraging rapid decision-making and multidisciplinary collaboration, the dual objectives of hemostasis and lung function preservation were successfully achieved, thereby enhancing the success rate of emergency and critical care. The primary threat posed by acute massive airway hemorrhage is the rapid influx of blood into the airway, leading to dual pathophysiological imbalances in both respiratory and circulatory systems. Traditional methods aim to control bleeding via physical isolation; however, their operational complexities often hinder effectiveness in emergency settings. The precise positioning of the double-lumen endotracheal tube relies on the guidance of fiberoptic bronchoscopy, and the average operation time is reported to be 8–10 minutes( 5 , 6 ). However, the average insertion time of the single-lumen endotracheal tube used in this study is only 2.5 minutes, significantly shortening the golden rescue window period. This difference is particularly critical in emergency scenes with blurred vision. Direct mechanical compression of the bleeding point by the single-lumen tube through the cuff allows rapid control of bleeding. In this study, the success rate of first compression hemostasis was 100% in all 8 cases, and the risk of blood clot occlusion caused by DLT lumen stenosis was avoided( 7 ). SpO₂ increased to more than 90% after intubation in all cases, which verified the effectiveness of one lung ventilation. Compared with the balloon tamponade technique of Correia et al( 8 ), cuff compression avoids the risk of lumen obstruction. In addition, single-lumen endotracheal intubation also has anatomical adaptability, which can flexibly adjust the depth of intubation according to the location of bleeding points. For central airway bleeding, the intubation depth can be extended to the distal end of the bleeding point, and local compression can be achieved by cuff tamponade. For unilateral main bronchus bleeding, intubation to the contralateral non-bleeding bronchus was combined with cuff fixation to carina, and both ventilation of the healthy lung and isolation of the affected side were taken into account. From the perspective of health economics, the cost of a single-lumen tube is only 1/5 of that of a bronchial blocker, and it does not need to rely on high-end equipment such as fiberoptic bronchoscopy, which is suitable for all medical institutions, including primary medical institutions. Universal first aid measures are in line with the concept of " step-down emergency care" proposed by Sandu et al( 9 ). Most of the previous literature advocated that the affected lung should be placed below to protect the oxygenation of the healthy side, but this study achieved a balance between "oxygenation" and "lung protection" through dynamic positioning. The head down position can be assisted by gravity to drain blood in cooperation with negative pressure suction to reduce blood backperfusion to the distal alveoli. Slight elevation of the affected side during the controlled bleeding stage can preserve the visual field for the surgeon and avoid completely sacrificing the lung function of the affected side. When the bleeding was out of control, the position was immediately adjusted to "head down and feet high + the affected side down", and the ventilation of the healthy side was given priority. This strategy was consistent with the "damage control" concept proposed by Wang et al ( 2 ) . Five patients experienced cardiac arrest during the operation, all accompanied by a sudden drop in SpO₂ to 0%, indicating the direct impact of hypoxia on the myocardium. At this point, anti-shock treatment should be initiated simultaneously rather than relying solely on hemostasis. Although ECMO was not actually applied in this study, all four deceased patients had DIC and multiple organ failure, suggesting that the application of ECMO in such patients requires comprehensive assessment. Limitations Sample bias: The sample size was only 8 cases, and 75% (6/8) were patients with malignant tumors, which may overestimate the applicability of the technique for benign lesions (such as tuberculosis). Future studies need to verify the efficacy through extensive promotion and application. Lack of postoperative and long-term functional follow-up: There was no postoperative lung CT, lung function, or quality of life data. No application of ECMO: Although the theoretical advantages of ECMO were mentioned, it was not actually applied. Summary The essence of treating acute massive airway hemorrhage is a "race against time", and dynamic development assessment runs through the entire process of treating acute massive airway hemorrhage. This study establishes that the ABCDE protocol-guided strategy, featuring single-lumen tube compression hemostasis and dynamic positional adjustment, which achieving dual therapeutic advantages in acute massive airway hemorrhage: rapid bleeding control and lung function preservation. Its inherent simplicity, anatomical adaptability, and multifunctional design significantly enhance emergency response efficiency and clinical outcomes. Declarations Conflicts of interest/financial All authors have no potential competing interests to declare. TRIAL REGISTRATION not applicable. Human Ethics and Consent to Participate This study was approved by the Medical Research Ethics Committee of Emergency General Hospital in Beijing, China. All patients of Interventional Pulmonology Center were informed that the patients' clinical data might be used in clinical studies and signed the informed consent form on admission and before bronchoscopy intervention therapy. I confirm that methods of this study were performed in accordance with the relevant guidelines. Consent for publication Not applicable. Competing interests All authors have no potential competing interests to declare. Funding The authors declare that they have no funding. Author Contribution Study conception: MY, QC. Study design: MY, QC. Study conduct: MY, QC. Data analysis: MY. Data interpretation: MY, QC. Drafting of the manuscript: MY, HW, QC. All authors approved the final version of the manuscript. Acknowledgements Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author. References Yang M, Zhou Y, Li H, Wei H, Cheng Q. Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage. BMC Pulm Med. 2023;23(1):483. Wang S, Ye Q. Association between blood pressure and the risk of biopsy-induced endobronchial hemorrhage during bronchoscopy. BMC Pulm Med. 2022;22(1):25. Son JH, Kim DH, Lee SK. Successful use of an EZ-blocker for lung isolation and management in a hemoptysis patient. Annals translational Med. 2019;7(22):701. Correia S, Dionisio J, Duro da Costa JJ. Modified technique of endobronchial balloon tamponade for persistent hemoptysis. J Bronchol Interv Pulmonol. 2014;21(4):361–5. Sethi RKV, Khatib D, Kligerman M, Kozin ED, Gray ST, Naunheim MR. Laryngeal fracture presentation and management in United States emergency rooms. Laryngoscope. 2019;129(10):2341–6. Kim JG, Ahn C, Kim W, Lim TH, Jang BH, Cho Y, et al. Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne). 2023;10:1193514. Nedunchezhian V, Nedunchezhian I, Van Zundert A. Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review. Healthc (Basel). 2023;11(17). Correia S, Dionísio J, Duro da Costa JJ. Modified technique of endobronchial balloon tamponade for persistent hemoptysis. J Bronchol Interv Pulmonol. 2014;21(4):361–5. Pincet L, Lecca G, Chrysogelou I, Sandu K. External laryngotracheal trauma: a case series and an algorithmic management strategy. Eur Arch Otorhinolaryngol. 2024;281(4):1895–904. Tables Table1 Patient preoperative details and hemorrhage characteristics 8Patients Age 57.25years (range: 36y-81y) Sex 5men and 3 women Diagnosis N % Primary lung cancer 3 37.5% Metastatic lung cancer 3 37.5% Gastric cancer 1 12.5% Thyroid cancer 1 12.5% Liver cancer and Gastric cancer 1 12.5% Aspergillosis pneumonia 1 12.5% Polychondritis 1 12.5% Stenosis degree of lesion 83% (50%-100%) Preoperative KPS score 63.75(50-90) Preoperative mMRC score 2.625(1-4) Lesion location Main airway 3 37.5% Left main bronchus 2 25% Right main bronchus 3 37.5% Procedural factors contributing to bleeding Tumor excision 5 62.5% Transbronchial lung biopsy 1 12.5% Dilatation and tears 1 12.5% Spontaneous tumor hemorrhage 1 12.5% Table 2 Intraoperative hemostasis management and patient outcomes Management Hemostasis methods Endotracheal intubation 8 100% Post-operative emergency vascular embolization 3 37.5% Adverse events Intra-operative hypoxemia 8 100% Intraoperative lowest SpO 2 3.75（0-20） Intraoperative hemorrhagic shock 5 67.5% Intraoperative cardiac arrest 5 67.5% Intraoperative mortality 0 0 Outcomes Postoperative transfer to ICU 8 100% Duration of operation 100 min (50min-190min) Volume of blood loss 2137. 5 ml (800ml-3600ml) Post-operative mortality 4 50% Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6598199","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469275576,"identity":"63bfbc08-1042-4b36-92b6-82c92036c830","order_by":0,"name":"Mingyuan Yang","email":"","orcid":"","institution":"Emergency General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingyuan","middleName":"","lastName":"Yang","suffix":""},{"id":469275577,"identity":"27e067b7-b098-46dd-b471-41040712ee21","order_by":1,"name":"Huafeng Wei","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Huafeng","middleName":"","lastName":"Wei","suffix":""},{"id":469275578,"identity":"fe423849-3f43-49d1-b819-acd011990fe3","order_by":2,"name":"Qinghao Cheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYFACHgaDBAMJOTb29gPEayn4UGFjzMdzJoF4LR9nnElLnCfhYECcBv723IObedsOp7dJMCQw/KjYRliLxJl3ycZALblt0o0HGHvO3CasxUAixwyiReZAAjNjG3FazH+DHMYmkWBAtBYDQ6D3E4jXInHmjYEBMJAN24CBfJAov/C35xiAolJevr394IMfFURoYQAGLRwcIEY9qpZRMApGwSgYBVgBAP/IPF/FGafuAAAAAElFTkSuQmCC","orcid":"","institution":"Emergency General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qinghao","middleName":"","lastName":"Cheng","suffix":""}],"badges":[],"createdAt":"2025-05-06 02:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6598199/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6598199/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84644553,"identity":"5de15052-18d2-4ce6-86d8-a8cadcf0b77d","added_by":"auto","created_at":"2025-06-15 16:14:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154919,"visible":true,"origin":"","legend":"\u003cp\u003eABCDE protocol\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6598199/v1/2c25768c45e7007357be04dd.jpg"},{"id":84644552,"identity":"e5f6c9f3-c0df-4cb8-a715-bdcd34d37ac0","added_by":"auto","created_at":"2025-06-15 16:14:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":117902,"visible":true,"origin":"","legend":"\u003cp\u003eLocalization of compression hemostasis by single lumen endotracheal intubation and changes in positioning\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6598199/v1/29eecf231702b4a49a841900.jpg"},{"id":95720570,"identity":"d6b385f2-de82-4e81-8397-a77b6276b89d","added_by":"auto","created_at":"2025-11-12 09:25:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":961122,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6598199/v1/c1b079f8-0e9a-4f8a-bf6f-4a9e7b43d6b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Lumen Endotracheal Intubation Combined with Dynamic Positioning for Bronchoscopy- Associated Acute Massive Airway Hemorrhage: A Case Series Based on ABCDE protocol","fulltext":[{"header":"KEY POINTS","content":"\u003cp\u003eBronchoscopy associated acute massive airway hemorrhage (BAMAH) is life-threatening. There is no systematic rescue process and method, and traditional hemostasis methods are limited by their complexity.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study establishes that the ABCDE protocol-guided strategy (Airway-Bleeding-Circulation-Disposal- Endotracheal Intubation), featuring single-lumen tube compression hemostasis and dynamic positional adjustment, which achieving dual therapeutic advantages in acute massive airway hemorrhage: rapid bleeding control and lung function preservation. It enables structured management and achieves rapid hemostasis and lung protection. Meanwhile its inherent simplicity, anatomical adaptability, and multifunctional design significantly enhance emergency response efficiency and clinical outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eBronchoscopy-associated acute massive airway hemorrhage was defined as massive hemorrhage of more than 100 ml caused by bronchoscopy intervention therapy, with rapid outflow of blood from the bleeding point, blurred vision of bronchoscopy, inability to stop bleeding quickly, and blood filling the alveoli, which seriously affects the oxygen supply function of the lung lobes(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It represents the most severe complication associated with bronchoscopy diagnosis and treatment, characterized by a low incidence rate but high mortality(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In such time-critical emergencies, clinicians face chaotic scenarios where a standardized emergency protocol and a rapid, technically simple intervention are imperative to seize the narrow 1\u0026ndash;2 minutes window for successful resuscitation after failed conventional measures.\u003c/p\u003e \u003cp\u003eCurrent management strategies prioritize pulmonary isolation and hemostasis, employing tools such as endoscopic balloon occlusion, double-lumen endotracheal tubes (DLTs), and bronchial blockers. However, these methods suffer from intrinsic limitations in emergency practical application: endoscopic balloons require concurrent use with other ventilation devices and cannot function independently; bronchial blockers and double-lumen endotracheal tubes necessitate precise positioning under bronchoscopy guidance\u0026mdash;a time-consuming process further complicated by narrow lumens prone to clot obstruction. These limitations significantly reduce their practicality in emergency settings, highlighting the urgent need for a simpler and more efficient solution. Tracheal intubation, traditionally viewed as a tool primarily for airway ventilation, can be leveraged more flexibly in emergencies to extend its utility beyond ventilation. For instance, PVC single-lumen tracheal intubation, due to its ease of locating, can achieve lung isolation and pressure hemostasis through its cuff, demonstrating potential advantages in managing acute massive airway bleeding. Compared to endoscopic balloons and bronchial blockers (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), this approach theoretically eliminates clot occlusion risks and reduces procedural time\u0026mdash;critical advantages in hemorrhagic crises. This study aims to explore the hemostatic effects of single-lumen endotracheal intubation with cuff compression, and validate the clinical utility of an ABCDE-based emergency protocol (Airway assessment, Bleeding stratification, Circulatory support, Disposal interventions, Endotracheal intubation) for treating acute massive airway hemorrhage. Through analysis of 8 protocol-driven cases, the necessity of standardization emergency airway management was fully demonstrated, providing a novel perspective for emergency interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study analyzed electronic medical records of patients who underwent bronchoscopy interventional therapy at the Respiratory Endoscopy Center of Emergency General Hospital between January 2004 and December 2021. Ethical approval for this study (Ethical Committee number: K21-39) was provided by the Ethical Committee of Emergency General Hospital, Beijing, China on 29 November 2021. All patients of Respiratory Endoscopy Center were informed that the patients' clinical data might be used in clinical studies and signed the informed consent form on admission and before bronchoscopy intervention therapy.\u003c/p\u003e \u003cp\u003eInclusion Criteria includes: experienced bronchoscopy-associated acute massive airway hemorrhage during the procedure and required compression hemostasis via endotracheal intubation; possessed complete perioperative records. Exclusion Criteria includes: non-acute massive hemorrhage; acute massive hemorrhage managed successfully via endoscopic balloon compression without requiring endotracheal intubation; incomplete medical records.\u003c/p\u003e \u003cp\u003eEight patients occurred acute massive airway hemorrhage intraoperatively and was managed through compression hemostasis via tracheal intubation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eManagement strategy in process of rescue and disposal\u003c/h3\u003e\n\u003cp\u003eOnce airway bleeding occurs during the operation, it is imperative to remain calm, assess the severity of the bleeding, and select the appropriate rescue disposal method adherence to a predefined standardized protocol to ensure timely and effective intervention. The management strategies for bronchoscopy-associated acute massive airway hemorrhage differ significantly from those for non-acute massive hemorrhage. A structured ABCDE-based protocol is systematically applied, prioritizing critical evaluations of airway assessment, bleeding extent, and circulatory function. This approach ensures a seamless transition from initial assessment (A-B-C) to targeted interventions (D-E), enabling rapid stabilization and definitive hemostasis. (as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eABCDE Protocol\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eA: Airway assessment.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the diagnosis of acute massive airway hemorrhage, airway assessment is the primary and crucial step, mainly including the following three aspects:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLocalization of Bleeding Site: Identify the precise origin of hemorrhage (main airway, left/right main bronchus, or carina).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluation of Concurrent Airway Pathology: Assess structural abnormalities (e.g., stenosis, tumors, or mucosal lesions) in non-bleeding areas to ensure safe intubation and airway patency.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOxygenation and ventilation management: Continuously monitor the patient's oxygenation status (SpO₂ and arterial blood gas), adjust ventilator parameters to ensure adequate oxygen supply to the patient, and cooperate with the surgeon to complete hemostasis operations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eB: Bleeding extent\u003c/h3\u003e\n\u003cp\u003eAssessment of bleeding extent involves evaluating three critical dimensions: speed, volume, and clinical impact, which collectively guide intervention prioritization.\u003c/p\u003e \u003cp\u003e1. Bleeding speed: Patients are stratified into two categories based on the bleeding speed: non-acute bleeding and acute bleeding.\u003c/p\u003e \u003cp\u003eNon-acute bleeding: Slow hemorrhage rate allowing clear endoscopic visualization, allowing proceed with local hemostasis and bronchoscopy interventions.\u003c/p\u003e \u003cp\u003eAcute bleeding: Rapid hemorrhage and blood rapidly fills the airway causing obscuration of endoscopic vision or even complete obscuration of anatomical landmarks, needing immediate escalation to advanced hemostatic methods.\u003c/p\u003e \u003cp\u003e2. Bleeding volume: As the cumulative bleeding volume increases, it not only affects alveolar oxygenation function but also impacts the systemic circulation and coagulation function.\u003c/p\u003e \u003cp\u003eThe stepwise management of acute massive airway hemorrhage prioritizes sequential interventions based on bleeding speed and volume, outlined as First-line: Endoscopic Balloon Tamponade; Second-line: Endotracheal Intubation with Hemostatic Compression; Third-line: Bronchial Artery Embolization.\u003c/p\u003e\n\u003ch3\u003eC: Circulation function\u003c/h3\u003e\n\u003cp\u003eThe effects of acute massive airway hemorrhage on the circulatory system primarily encompass circulatory dysfunction due to hypoxia and reduced blood volume. These two factors synergistically exacerbate the patient's condition, necessitating prompt measures to ensure adequate blood volume and preparation of vasoactive drugs. According to the changes of blood loss and circulation capacity, appropriate rehydration, blood preparation and antishock therapy should also be performed and considered.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEffects of Hypoxia on Circulatory Function: Acute massive hemorrhage results in blood backflow into the alveoli, disrupting gas exchange. This leads to a rapid decrease in blood oxygen levels (hypoxemia), causing tissue hypoxia. Hypoxia-induced cardiac dysfunction, including decreased cardiac output and myocardial ischemia, can occur early and progress rapidly, making it challenging to correct quickly. Prioritizing interventions to restore oxygen delivery, such as airway clearance and intubation, is crucial.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEffects of Hypovolemia on Circulatory Function: Acute massive hemorrhage causes a rapid reduction in circulating blood volume, leading to hypovolemic shock. This reduces cardiac preload and cardiac output, resulting in inadequate tissue perfusion and potentially exacerbating multiple organ dysfunction. Compared to hypoxia-induced circulatory disturbances, hypovolemia-induced circulatory disturbances may occur later but have a significant impact on blood pressure and perfusion. Timely blood volume replacement, such as transfusion or rehydration, is essential for correcting these issues.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExtracorporeal Membrane Oxygenation (ECMO): ECMO is capable of maintaining oxygenation and stabilizing circulatory function, guaranteeing the perfusion of crucial organs and providing conditions for interventional hemostasis via bronchoscopy, surgical hemostasis, and interventional vascular embolization hemostasis. Nevertheless, systemic anticoagulation is necessary for ECMO to prevent tubing thrombosis. However, during massive airway hemorrhage, anticoagulation might aggravate the bleeding. The dosage of heparin can be adjusted to the lower limit by monitoring ACT (activated clotting time) or APTT. Even for patients with an extremely high risk of bleeding, anticoagulation can be temporarily suspended. Anticoagulation management is the key to success and requires a comprehensive decision based on bleeding and coagulation status. The ultimate objective is to withdraw ECMO as early as possible after successful hemostasis to avoid complications.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eD: Disposal\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDrug hemostasis: Intravenous infusion of hemostatic drugs, coagulation factors, plasma infusion, etc.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEndoscopic hemostasis: Endoscopic hemostasis involves bronchoscopy lavage of frozen saline, diluted epinephrine (1:10 000\u0026ndash;1:10 000), thrombin into the local bronchus and thermal coagulation of the bleeding point by APC, electropuncture, electrocoagulation, laser to burn the bleeding point, and endoscopic balloon can also be used for local compression to stop bleeding.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOperation position: Place the patient in the Trendelenburg position and prepare an additional negative pressure suction device to facilitate blood drainage, thereby preventing blood from flowing into the distal alveoli and compromising lung function. In cases of controllable hemorrhage, it is unnecessary to directly elevate the non-bleeding side; instead, slightly elevate the bleeding side. This positioning strategy under a gradient Trendelenburg posture minimizes blood entry into the non-bleeding lung while preserving the oxygenation capacity of the distal non-bleeding alveoli in the affected lung. In cases of uncontrollable massive hemorrhage, immediately reposition the patient to a modified Trendelenburg with lateral decubitus (bleeding lung positioned inferiorly, non-bleeding lung superiorly). This configuration prioritizes ventilation and oxygenation of the non-bleeding lung.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eE: Endotracheal intubation\u003c/h2\u003e \u003cp\u003eWhen the bleeding rate is too fast, bronchoscopy hemostasis cannot be performed because blood rapidly fills the airway, obscuring the field of view. The blood is constantly pouring out, and effective measures to stop the bleeding should be taken immediately. If the source of bleeding cannot be identified following a rapid assessment, or if the bleeding originates from a major artery, blind hemostasis is not expected to be successful. Instead, the rigid bronchoscope or flexible bronchoscope should be promptly removed, and replaced with a poly vinyl chloride (PVC) material endotracheal intubation tube (preferred size of 7.5 and 8.0). At the same time, change to Trendelenburg position with the bleeding lung down.\u003c/p\u003e \u003cp\u003eThe location of the intubation varies according to the bleeding site (shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). If the bleeding is at the central tracheal airway beyond carina, intubate to the distal end of the bleeding site and use the capsule of the intubate to compress the bleeding. If the bleeding site is on one side of lung, the tube is cannulated to the opposite main bronchus without bleeding, and the capsule is fixed on the carina. The proper placement of the capsule on the carina can not only seal the blood extravasation from the bleeding lung, but also ensure the normal ventilation of the contralateral un-bleeding lung.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe specific steps are as follows: First, quickly insert the PVC tube into non-bleeding main bronchus by an experienced anesthesiologist. Secondly, adjust and fix the capsule at the carina by experienced endoscopist under the guide of flexible bronchoscope to stop blood spilling out from the bleeding lung. Thirdly, fully attracted the blood and secretion of the non-bleeding lung. Due to the high airway pressure at this time, manual ventilation is recommended to maintain oxygenation. 15 minutes later, flexible electronic bronchoscope was inserted to check the bleeding after cuff release or to withdraw the endotracheal tube to the main airway. If airway bleeding is effectively controlled, rigid bronchoscope can be replaced to facilitate subsequent airway procedures, trying to open up some lobes or segments of the lung. If the bleeding is partially alleviated, the duration of compression can be appropriately prolonged. If hemostasis remains ineffective after multiple attempts of endotracheal intubation compression, priority should be given to sustaining the compression to provide a stable condition and additional time for subsequent surgical intervention or emergency bronchial arterial embolization.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 8 patients (5 males and 3 females, with a mean age of 57.25years) experienced severe bronchoscopy-associated acute massive airway hemorrhage. Among the eight patients, three were diagnosed with primary lung cancer, three with secondary lung cancer, and two with benign lesions, specifically aspergillosis pneumonia and polychondritis. The average degree of airway stenosis attributable to preoperative lesions was 83% (range:50%-100%), and all patients exhibited varying degrees of breath-holding symptoms preoperatively. The mean Karnofsky Performance Status (KPS) score was 63.75(range:50\u0026ndash;90), and the mean modified Medical Research Council (mMRC) dyspnea scale score was 2.625(range:1\u0026ndash;4).\u003c/p\u003e \u003cp\u003eThe lesions responsible for the hemorrhage were situated in the central airway (37.5%), specifically within the left or right main bronchus (62.5%). The causes of bleeding encompassed tumor tissue excision (62.5%), transbronchial lung Biopsy (TBLB) (12.5%), balloon dilatation and associated tears (12.5%), as well as spontaneous hemorrhage from the tumor (12.5%). All 8 patients ultimately underwent endotracheal intubation for compression hemostasis and one-lung ventilation. Three patients received emergency arterial embolization with the assistance of intubation compression to enhance hemostatic efficacy.\u003c/p\u003e \u003cp\u003eIntraoperative adverse events included hypoxemia, hemorrhagic shock, and cardiac arrest. Hypoxemia was observed in all eight patients, with six patients exhibiting a minimum oxygen saturation of 0%, while the remaining two patients had minimum oxygen saturations of 10% and 20%, respectively. It is noteworthy that hemorrhagic shock occurred during the procedure, leading to cardiac arrest in five patients. Fortunately, no patient experienced intraoperative mortality, and all eight patients were safely transferred to the ICU with successful compression hemostasis achieved and one-lung ventilation through endotracheal intubation. The mean duration of operation was 100 minutes (range:50min-190min), and the mean blood loss volume was 2137.5 ml (range:800ml-3600ml). Finally, four patients succumbed to severe postoperative complications, including multiple organ failure and disseminated intravascular coagulation (DIC), within 48 hours following the procedure.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcute massive airway hemorrhage is a recently introduced concept that further categorizes the condition from the original diagnosis of massive airway hemorrhage by emphasizing its acute nature, which reflects the critical and severe state. In this study, eight cases of bronchoscope-related acute airway hemorrhage were analyzed, and an innovative emergency strategy was proposed, which integrates single-lumen endotracheal tube compression hemostasis with dynamic positional adjustment based on \"ABCDE\" protocol. \"ABCDE\" protocol encompasses airway assessment, bleeding extent, circulatory function, disposal process, and endotracheal intubation. By closely integrating with clinical practice and leveraging rapid decision-making and multidisciplinary collaboration, the dual objectives of hemostasis and lung function preservation were successfully achieved, thereby enhancing the success rate of emergency and critical care.\u003c/p\u003e \u003cp\u003eThe primary threat posed by acute massive airway hemorrhage is the rapid influx of blood into the airway, leading to dual pathophysiological imbalances in both respiratory and circulatory systems. Traditional methods aim to control bleeding via physical isolation; however, their operational complexities often hinder effectiveness in emergency settings. The precise positioning of the double-lumen endotracheal tube relies on the guidance of fiberoptic bronchoscopy, and the average operation time is reported to be 8\u0026ndash;10 minutes(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, the average insertion time of the single-lumen endotracheal tube used in this study is only 2.5 minutes, significantly shortening the golden rescue window period. This difference is particularly critical in emergency scenes with blurred vision. Direct mechanical compression of the bleeding point by the single-lumen tube through the cuff allows rapid control of bleeding. In this study, the success rate of first compression hemostasis was 100% in all 8 cases, and the risk of blood clot occlusion caused by DLT lumen stenosis was avoided(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). SpO₂ increased to more than 90% after intubation in all cases, which verified the effectiveness of one lung ventilation. Compared with the balloon tamponade technique of Correia et al(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), cuff compression avoids the risk of lumen obstruction. In addition, single-lumen endotracheal intubation also has anatomical adaptability, which can flexibly adjust the depth of intubation according to the location of bleeding points. For central airway bleeding, the intubation depth can be extended to the distal end of the bleeding point, and local compression can be achieved by cuff tamponade. For unilateral main bronchus bleeding, intubation to the contralateral non-bleeding bronchus was combined with cuff fixation to carina, and both ventilation of the healthy lung and isolation of the affected side were taken into account. From the perspective of health economics, the cost of a single-lumen tube is only 1/5 of that of a bronchial blocker, and it does not need to rely on high-end equipment such as fiberoptic bronchoscopy, which is suitable for all medical institutions, including primary medical institutions. Universal first aid measures are in line with the concept of \" step-down emergency care\" proposed by Sandu et al(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost of the previous literature advocated that the affected lung should be placed below to protect the oxygenation of the healthy side, but this study achieved a balance between \"oxygenation\" and \"lung protection\" through dynamic positioning. The head down position can be assisted by gravity to drain blood in cooperation with negative pressure suction to reduce blood backperfusion to the distal alveoli. Slight elevation of the affected side during the controlled bleeding stage can preserve the visual field for the surgeon and avoid completely sacrificing the lung function of the affected side. When the bleeding was out of control, the position was immediately adjusted to \"head down and feet high\u0026thinsp;+\u0026thinsp;the affected side down\", and the ventilation of the healthy side was given priority. This strategy was consistent with the \"damage control\" concept proposed by Wang et al (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eFive patients experienced cardiac arrest during the operation, all accompanied by a sudden drop in SpO₂ to 0%, indicating the direct impact of hypoxia on the myocardium. At this point, anti-shock treatment should be initiated simultaneously rather than relying solely on hemostasis. Although ECMO was not actually applied in this study, all four deceased patients had DIC and multiple organ failure, suggesting that the application of ECMO in such patients requires comprehensive assessment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSample bias: The sample size was only 8 cases, and 75% (6/8) were patients with malignant tumors, which may overestimate the applicability of the technique for benign lesions (such as tuberculosis). Future studies need to verify the efficacy through extensive promotion and application.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLack of postoperative and long-term functional follow-up: There was no postoperative lung CT, lung function, or quality of life data.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNo application of ECMO: Although the theoretical advantages of ECMO were mentioned, it was not actually applied.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSummary\u003c/h2\u003e \u003cp\u003eThe essence of treating acute massive airway hemorrhage is a \"race against time\", and dynamic development assessment runs through the entire process of treating acute massive airway hemorrhage. This study establishes that the ABCDE protocol-guided strategy, featuring single-lumen tube compression hemostasis and dynamic positional adjustment, which achieving dual therapeutic advantages in acute massive airway hemorrhage: rapid bleeding control and lung function preservation. Its inherent simplicity, anatomical adaptability, and multifunctional design significantly enhance emergency response efficiency and clinical outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest/financial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no potential competing interests to declare.\u003c/p\u003e \u003ch2\u003eTRIAL REGISTRATION\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eHuman Ethics and Consent to Participate\u003c/b\u003e \u003c/p\u003e \u003cp\u003e This study was approved by the Medical Research Ethics Committee of Emergency General Hospital in Beijing, China. All patients of Interventional Pulmonology Center were informed that the patients' clinical data might be used in clinical studies and signed the informed consent form on admission and before bronchoscopy intervention therapy. I confirm that methods of this study were performed in accordance with the relevant guidelines.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eAll authors have no potential competing interests to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy conception: MY, QC. Study design: MY, QC. Study conduct: MY, QC. Data analysis: MY. Data interpretation: MY, QC. Drafting of the manuscript: MY, HW, QC. All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYang M, Zhou Y, Li H, Wei H, Cheng Q. Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage. BMC Pulm Med. 2023;23(1):483.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang S, Ye Q. Association between blood pressure and the risk of biopsy-induced endobronchial hemorrhage during bronchoscopy. BMC Pulm Med. 2022;22(1):25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSon JH, Kim DH, Lee SK. Successful use of an EZ-blocker for lung isolation and management in a hemoptysis patient. Annals translational Med. 2019;7(22):701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorreia S, Dionisio J, Duro da Costa JJ. Modified technique of endobronchial balloon tamponade for persistent hemoptysis. J Bronchol Interv Pulmonol. 2014;21(4):361\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSethi RKV, Khatib D, Kligerman M, Kozin ED, Gray ST, Naunheim MR. Laryngeal fracture presentation and management in United States emergency rooms. Laryngoscope. 2019;129(10):2341\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JG, Ahn C, Kim W, Lim TH, Jang BH, Cho Y, et al. Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne). 2023;10:1193514.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNedunchezhian V, Nedunchezhian I, Van Zundert A. Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review. Healthc (Basel). 2023;11(17).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorreia S, Dion\u0026iacute;sio J, Duro da Costa JJ. Modified technique of endobronchial balloon tamponade for persistent hemoptysis. J Bronchol Interv Pulmonol. 2014;21(4):361\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePincet L, Lecca G, Chrysogelou I, Sandu K. External laryngotracheal trauma: a case series and an algorithmic management strategy. Eur Arch Otorhinolaryngol. 2024;281(4):1895\u0026ndash;904.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable1 Patient preoperative details and hemorrhage characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"653\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e57.25years (range: 36y-81y)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e5men and 3 women\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003ePrimary lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eMetastatic lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eGastric cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eThyroid cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eLiver cancer and Gastric cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u0026nbsp; Aspergillosis pneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u0026nbsp; Polychondritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3287%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12.657%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStenosis degree of lesion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e83% (50%-100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative KPS score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e63.75(50-90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative mMRC score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e2.625(1-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLesion location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27.1052%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eMain airway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eLeft main bronchus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eRight main bronchus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcedural factors contributing to bleeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u0026nbsp; Tumor excision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e62.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eTransbronchial lung biopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003e\u0026nbsp; Dilatation and tears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.1056%;\"\u003e\n \u003cp\u003eSpontaneous tumor hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0303%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7169%;\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 Intraoperative hemostasis management and patient outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"653\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 73.0159%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemostasis methods\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003ePost-operative emergency vascular embolization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 73.0159%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdverse events\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eIntra-operative hypoxemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eIntraoperative lowest SpO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 28.1746%;\"\u003e\n \u003cp\u003e3.75（0-20）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eIntraoperative hemorrhagic shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e67.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eIntraoperative cardiac arrest\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e67.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eIntraoperative mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 28.1746%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003ePostoperative transfer to ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eDuration of operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 28.1746%;\"\u003e\n \u003cp\u003e100 min (50min-190min)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003eVolume of blood loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 28.1746%;\"\u003e\n \u003cp\u003e2137. 5 ml (800ml-3600ml)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.8413%;\"\u003e\n \u003cp\u003ePost-operative mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9471%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2275%;\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6598199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6598199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003cbr\u003e\nBronchoscopy-associated acute massive airway hemorrhage (BAMAH) is a life-threatening emergency requiring rapid intervention. Traditional methods face challenges in emergency settings due to operational complexity and clot occlusion risks. This study evaluates a novel ABCDE protocol guided strategy integrating single-lumen endotracheal intubation with dynamic positioning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e\u003cbr\u003e\nA retrospective case series analyzed 8 AMAH patients (2004–2021) managed at a tertiary hospital. The intervention combined single-lumen tube compression hemostasis (cuff-targeted mechanical tamponade) and dynamic positioning (Trendelenburg with lateral tilt). Outcomes included hemostasis success rate, oxygenation improvement, and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003cbr\u003e\nHypoxemia was observed in all eight patients, with six patients exhibiting a minimum oxygen saturation of 0%, while the remaining two patients had minimum oxygen saturations of 10% and 20%, respectively. The mean duration of operation was 100 minutes (range:50min-190min), and the mean blood loss volume was 2137.5 ml (range:800ml-3600ml). All patients achieved immediate hemostasis, post-intubation SpO₂ increased to ≥90%, and no mortality occurred intraoperatively. However, 50% mortality (4/8) was observed due to disseminated intravascular coagulation and multi-organ failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003cbr\u003e\nThe ABCDE protocol (Airway-Bleeding-Circulation-Disposal-Endotracheal intubation) provides a structured framework for managing BAMAH. Single-lumen intubation with dynamic positioning achieves dual goals: rapid hemostasis via cuff compression and lung protection through gravity-assisted drainage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTRIAL REGISTRATION: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Single-Lumen Endotracheal Intubation Combined with Dynamic Positioning for Bronchoscopy- Associated Acute Massive Airway Hemorrhage: A Case Series Based on ABCDE protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-15 16:14:45","doi":"10.21203/rs.3.rs-6598199/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59344492-776d-471f-a7ab-9797e52bd104","owner":[],"postedDate":"June 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-12T09:23:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-15 16:14:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6598199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6598199","identity":"rs-6598199","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}