I can't believe it's been 10 years. So actually Samira and I had just graduated from our IP fellowship when she thought to put this session together because it was something that we barely saw in our IP fellowship and was scary. And so we thought that if we found it scary, then other people probably would too. And so she put this together and it has been shockingly popular every year since then. And so we keep getting invited back, which we're really excited about. So I didn't wear red because I feel like I have enough red on my slides to make up for it. Hemoptysis, if you didn't know, is actually a hard, heavy metal band. And so they are sponsoring this talk. No, they're not sponsoring this talk, but I'm just going to pretend like they are because they show up on our slides. But anyway, without further ado, so really hemoptysis came and Hippocrates described it as the spitting of pus follows the spitting of blood and consumption follows the spitting of blood and death follows consumption. And this is such a depressing quote, and yet I feel like it sort of sums up how most of us feel about massive hemoptysis just because it's something that's scary and it's kind of depressing and you're not sure what to do with it. And that's how I feel this quote ends up. So let's start out with simple definitions. So the word hemoptysis means coughing up blood. So hemo is blood and tysis means spitting. And you can have minor or massive, that's how we divide it. And so minor is just blood streaks or tinge in the sputum and massive, to be fair, there's no really clear definition in our literature. It varies, if you're reading about it, anywhere from 150 to 600 milliliters in anywhere from four to 24 hours. Well that's super confusing. And you can't ask your patients, they're never going to be able to tell you how much blood they've coughed up, right? Because they cough up blood and they're petrified. And so they're not going to be able to say 100 mLs or 200 mLs or so on and so forth. But massive hemoptysis is not completely rare, right? Five to 15% of hemoptysis is actually massive hemoptysis. So thinking about definitions, there are some definitions for more of what we think about as minor hemoptysis. And if you think about terminology for adverse events, so one of the most common areas when we see hemoptysis is when we're doing transbronchial biopsies in the lungs. And so if you look at the CTCAE scale, so as far as adverse events, you can grade hemoptysis based on the effect that it's going to have on the human. So Grade 1 would be mild symptoms where you don't have to intervene. Grade 2, moderate symptoms where you might have to intervene. Grade 3, you might need a transfusion. Grade 4 would be life-threatening respiratory or hemodynamic compromise. And Grade 5 would mean death. And there is, if you don't know, a standardized definition of bleeding after transbronchial lung biopsies. And this was created by the Nashville Working Group as a consensus statement. So if you are doing transbronchial biopsies, this is something that's really helpful to know. It is not massive hemoptysis, but it's really nice to be able to grade the amount of bleeding you're having during your procedure if you do have any. So Grade 1 just means that you have to suction the blood for less than a minute. So pretty minimal, probably what we see in most of our cases. Grade 2, suctioning for more than a minute may be required or maybe you have to wedge your scope. And maybe you have some persistent bleeding after instilling some cold saline or thrombin, et cetera. Grade 3, you're going to have to intubate this patient, possibly selective intubation or using a bronchial blocker. Or you might have to cut your procedure short. And Grade 4 is persistent selective intubation for more than 20 minutes, new admission to the ICU or if they require transfusions, need for bronchial artery embolization or resuscitation. So this stuff is just really helpful to kind of keep in the back of your mind for all of us who are doing bronchoscopies, especially with transbronchial biopsies. But let's get back to massive hemoptysis. So since I said the definition is kind of confusing, I think a better way to think about it is how can you distinguish massive from minor? And really it's all about the effects that you're going to have on your body. So because the volume is difficult to quantitate, you really want to think about the magnitude of the effect on the person. So on their hemodynamics, is their gas exchange impaired? Are you aspirating blood clots out of their airway? And do you need to give them blood transfusions? I think if any of those are happening, then that qualifies as massive hemoptysis. And you want to keep in the back of your mind your anatomy. And I promise I will not go into an extended physiology or anatomy lecture. But just so that we remember, your lungs have a dual blood supply. So there are the pulmonary arteries and the bronchial arteries. The pulmonary arteries are a low-pressure system. The bronchial arteries are at systemic pressures. And it's the bronchial arteries that are the culprit in massive hemoptysis in about 90% of cases. And so if you have your pulmonary arteries are really the ones that supply the arterial supply to the lungs and provide gaseous exchange, the bronchial arteries only do about 1% of that. And these two systems are connected by anastomoses at the level of the bronchi and the pulmonary lobules. And so that gives you this small right-to-left shunt that accounts for about 5% of your pulmonary output. I won't go through this because this is more anatomy and physiology. But just so you know, this is sort of how everything connects. And you have this dual blood supply in the area of the lungs that connects together. If by chance you have your pulmonary circulation that's compromised because of hypoxic conditions, so whether that means that you have intravascular thrombus, vasculitis, or other lung diseases, your bronchial arteries can proliferate and enlarge. And they can start to replace your pulmonary circulation. And when that happens, as they're enlarging and proliferating, they're not doing so in a nice, organized way. You end up with these sort of fragile blood vessels that are replacing your pulmonary arterial circulation. And so when you think about massive hemoptysis, all of this physiology sort of has to come into your mind. So we want to be like Dr. House and his team and always come up with the right answer about what is going on and what is the cause of the massive hemoptysis. So I think the first thing that comes to most of our minds is malignancy. So you can have bronchial carcinomas, carcinoids, metastatic cancers, et cetera, that invade the bronchial walls, the airway walls. They can cause obstruction, but a lot of the time they can cause coughing and hemoptysis. Bronchogenic carcinoma is a super common cause of hemoptysis. About 20% of lung cancer patients will present at some point in the course of their trajectory with hemoptysis. Most of it, however, is not life-threatening. Massive terminal hemoptysis only happens, thankfully, in about 3% of patients with lung cancer. And it's really common, you can see with bronchial carcinoid tumors, that happens both when you biopsy them and even if you just leave them alone, they tend to bleed. Other things we think about, bronchiectasis and infection. So you can have these cavitary areas in your lung, as you can see on the top and the middle photos. Those tend to bleed a lot. So that's bronchiectasis, mycobacterial cavitary lung disease with fungal and abscesses. You can have necrotizing pneumonias. And then you can have a whole bunch of different parachromosis, hidatid cysts, et cetera. With bronchiectasis, again, the bronchial circulation supplies the blood flow to the bronchial wall. And it's, again, at systemic pressures. So if you have this chronic inflammation, your blood vessels become torturous and they become really fragile. In active TB, you can see hemoptysis both with cavitary and non-cavitary disease. The reason is you can get bronchiolar ulceration. So you can get necrosis of the adjacent blood vessels and the distal alveoli. And again, if your bronchial arterial circulation starts to bleed, it's at systemic pressure. So you're going to end up with massive hemoptysis. You can also have Rasmussen's aneurysms, which are aneurysms of the pulmonary arteries. They can slowly expand because of inflammatory erosion and then eventually rupture and again cause massive hemoptysis. Even if it's not active TB, if you have prior tuberculosis, you can end up having erosion of healed and calcified lymph nodes into the airway wall. So this is an example of one of my patients who was having an erosion of a calcified node into their bronchial wall. And that can cause pretty significant hemoptysis depending on where it's located, which blood vessels are surrounding that. And then you can have some vascular problems. So you can have pulmonary embolisms or infarcts. You can have vasculitides. You can have a bronchovascular fistula. We see that sometimes when you have lung transplantation. If you're instrumenting your patients with PA catheters, those can rupture the vasculature. And you can have ruptured thoracic aneurysms or arterial venous malformations. All of these things, these lists should come into your mind when thinking about your patients. And then you can have different things. So you can have catamenial hemoptysis. So if it happens in a woman who gets their period and it's happening on a cyclic monthly basis, that should come to your mind. So foreign bodies or broncholiths can cause hemoptysis if they're anticoagulated with different medications and their airways get irritated. If they have LAM or some trauma, if they're doing drugs like cocaine or if they're even taking prescribed drugs like Bevacizumab, they can have hemoptysis. And one note is that something that's not hemoptysis is epistaxis and GI bleed. And those often get confused for massive hemoptysis. So how much volume do we have in our airways? Does anybody know? 150 mLs, right? Yeah. So it really doesn't take a lot. If you think about 100 mLs, right, less than a can of Coke, that's all the blood it takes to completely fill your airways. And so this is why all of this stuff, even though it seems like it might not cause that much bleeding, it really can cause more than enough to be considered massive hemoptysis, cause hemodynamic compromise, asphyxiation, and death, right? And it depends where you are in the world what are going to be the biggest, most common causes. So in some places, bronchiectasis or tuberculosis are going to be the most common reasons. In other places, cancer is going to be a more common reason for massive hemoptysis. And so again, about 5-15% of all massive hemoptysis is life-threatening. It happens in about 20% of all lung cancer patients over the course of their illness, and about 4% of our CF patient population. The mortality is worse at the beginning when they first have their massive hemoptysis, so as they're first presenting to you, that initial time period is really critical. And then mortality lessens as they survive those first few hours. All right. So how do we assess these patients? This stuff is pretty common, right? You're going to take your normal history, but you want to focus on all of these reasons why you could get hemoptysis. So first question, is this truly hemoptysis? So make sure it's not epistaxis or GI bleeding. And then ask about lung, cardiac, kidney diseases. Any prior hemoptysis? Do they have any infectious symptoms? Is this something that's coming every month or on a regular basis? How much blood is coming out? Do they have any chest pain, any family histories, travel histories, exposures, et cetera? Looking at physical exam, you want to think about cachexia, telangiectasia, saddle nose deformities. All of these physical exam findings are going to give you clues as to the etiology of the massive hemoptysis and can steer you in the right direction. And once you have a direction, then you'll order your labs or your ancillary testing, right. Somebody's going to get a CBC, a complete metabolic panel, COAGS, probably an ABG. And then the other testing is going to be based on your history and physical exam findings, right. And you can hone it in to try and figure out your etiology and your diagnosis. And then important radiographic features. So sometimes on your X-ray or on your CT scan you're going to have something that's going to localize your bleeding for you. That makes life a little bit easier. And other times you're going to have bilateral issues. So you can see that on the bottom right-hand side of the screen where you don't know where the bleeding is going to come from. So chest X-ray about 17% of the time will help you to localize or lateralize. CT scan about 70%. If you do bronchoscopy with CT scan, you get about 80% chance of localizing or lateralizing. And then about 5-10% of patients, you can do all of these things and you still have no explanation for where the bleeding is coming from. But most of those patients, the hemoptysis tends to resolve, tends not to be massive, and it ends up following a benign course. And with that, I'm going to pass you along to our next speaker. So I'm going to talk to you about the early management of massive hemoptysis. And that's really mostly just stabilizing your patient. Dr. Lam will talk in detail about how you actually manage the patient, meaning take care of their bleeding in not a temporary fashion, but in a permanent fashion. So our goal here is to just stabilize. I have no conflict of interest. So this is a heavy metal band. Their name is actually hemoptysis. They haven't been active for, I think, years. I'm not promoting them, but I have used their logo. So no conflict there. And so what did we do for massive hemoptysis management? So this is a picture I've had for years in all of these talks, and I've never found something better. This is from 1927. And so you can see a doctor holding the patient to their side, and the patient's coughing up blood. It looks like he's probably holding the patient's hand. Maybe he's checking for the pulse. And there was really nothing else. There was, of course, prayer, and that was really it. There was not much more to do. A little bit about prognostic indicators, once we start in talking about how to manage the patient. So Dr. Argento went over most of these. What I want to really specify, which is very, very important, is aspiration to the contralateral lung. That's what you're trying to avoid. That's absolutely the most important goal as you're taking care of your patient in those early stages. There are other things that could identify a patient as going to probably do worse. One of them is that your patient could have a diagnosis that is, let's say, malignancy. So those patients may have a more stubborn disease to manage. Another one is aspergillomas. Those are recurrent. And one more is bronchiectasis, actually, which responds beautifully to bronchial artery embolization, but it comes back pretty quickly. So a couple of things to keep in mind are those patients. Now, how do you manage massive hemoptysis? It doesn't happen often. It's actually not very common. We all do deal with hemoptysis, but massive hemoptysis is different. So if you don't see it regularly, how do you not panic when you want to take care of that patient? We have a musical theme here. But really, the idea, the most important thing, is preparedness. And the initial approach, which I will go over through the next slides, is something that you would need to use and develop a drill so that your patient's care is always similar as you go through your process. So here's the first step. Putting your patient on their bad side, the bleeding side down. I've seen it overlooked so frequently, and it is so important. Here's a patient who had been bleeding in the bronchoscopy suite, had eventually come to the OR for management. But because they were placed entirely on their side, blood had clouded on one side and had not spilled to the other side. So this can buy you a lot of time. When I talk to my fellows in the procedure suite and I ask them to turn the patient to their bad side down, what I mean is really turn the patient down. So their good side, lung, shoulder, hip, and ankle is facing the ceiling. You really turn the patient. And keep your bronchoscope in place if your bronchoscope is in the airway. How about establishing a patent airway? So you may be in the ER, or you may be in another hospital, and you get a call. There's a patient who's bleeding, and they want to send the patient to you for further management. And they tell you on the phone, don't worry. The patient now has a stable airway. Always take that with a grain of salt. The next question you want to ask is, where is the ET tube? Most of the time, what they mean by a stable airway, they have a secure airway, is that the airway, the ET tube, is in the trachea. That's not a secure airway. So the airway you want to secure is the one that is not bleeding. And so your ET tube is either in the area that is not bleeding, or you don't have a secure airway. So you have to have other methods to prevent blood from spillage. Now we'll talk a little bit about the size, but I've highlighted this here. Eight really is the minimum size. And I think Dr. Lam will also talk about this, but very, very important to have a good size ET tube. A lot of us don't have size nine ET tube in our bronchoscopy suites. It depends on where you do your procedures. If you're in, let's say, the bronchoscopy suite, you may have different things around you as opposed to the OR. So you really want to have a good size airway. 8.5 is my go-to, but you could also have eight if you really, really have to put an airway and there's not a better size airway than, let's say, 7.5. You want to keep in mind, gosh, I'm not going to be able to put a bronchial blocker with ease. So something to keep in mind, which is very important. How about double luminary tubes? We have one person who works in the ED, but beside this one person, Dr. Perry, anybody else has ever dealt with brisk bleeding and has put in a double luminary tube? Okay, I see one hand, half raised, two. How did it go? Disaster. Disaster. Thank you very much. So remember that in your head. Don't put a double luminary tube in a patient with massive hemoptysis. There are a number of reasons. One, it's even under the best of circumstances, it's hard to put in. But also, it's hard to stabilize. The lumens are tiny. How do you verify where your tube is? You use a pediatric scope. What can you do with a pediatric scope in a setting of bleeding? Absolutely nothing. You can't suction, you can't even see. And so here's what happens. Your ET tube gets entirely filled with blood on both sides. You can suction the other side, your ET tube is so full of blood, you can't really pass a catheter or anything else in there. You can't really suction blood. And so this is an absolute no. If you really have to, just do a single lumen intubation. Now that means you know where the blood is coming from. So if you want to intubate on the right or left side, that means you know that the blood is coming from right or left. And that's the next step that we're going to talk about. So the role of bronchoscopy. I think depending on where you are in the world and what's available to you in your institution, there is a variance between who would prefer going into bronchoscopy versus CT scan. For some people, CT scan is a lot easier and faster to use. If a bronchoscope is readily available to you, I recommend that because you can do more than just look inside the airway and suction the blood. You can also figure out where the blood is coming from. Now flexible bronchoscopy is helpful because you can do all of those things. There's also a question about using other methods of bronchoscopy, which we'll talk about. But take a look at CT scan here. So there is a large mass on the right side. There's actually a bronchoblocker here. This was done after the bronchoblocker was placed. But you could kind of tell where the blood is probably coming from. It's probably coming from the right side. What about this one? Where is the blood coming from, right or left? There's bronchitis on both sides. It's more on the right. But can you be convinced and say, I'm going to intubate on the left side to protect the left? You know for sure that the blood is not coming from the right side, the left side. What about this one? Where is the blood coming from, right? And so this is why I think a bronchoscopy would be helpful, because if you go inside the airway and take a look right and left side, and figure out the blood is coming from the right side, your goal is to protect the left side. If you have an ET tube on the left side and call me and say I have a secure airway, well done. And so that's why the role of bronchoscopy is significant here. How about rigid bronchoscopy? I think my go-to, if I have massive hemoptysis and I can't control the bleeding, is to consider rigid bronchoscopy. You have a large lumen, you have more than one method to suction. You can put a therapeutic bronchoscope, you could have a soft suction catheter, you could have a rigid suction, so you could control the bleeding very quickly. Having said that, I think we overemphasize the value of rigid bronchoscopy. First of all, it's not available to everyone. Secondly, not everyone has the skill set. But also, we often think of this scenario, where you have something in the airway that you can kind of zap, laser, whatever, and clear the bleeding and take care of the problem. The truth is that this actually doesn't happen very often. So most of the time when you have hemoptysis, the issue, the cause of the bleeding is not right there within the airway where you can see it and say, okay, well, there's a tumor here, it's bleeding, I'm going to remove the tumor, I'm going to put a stent. No, this actually doesn't happen often. And so, flexible bronchoscopy can get you a long way. All right, a little bit about balloon tamponade. So, there are reports of all manner of balloons used in the airway, from Foley catheters to CRE balloons to Fogarty catheters. But there are actually balloons that are designed for this. There are two types in the U.S. I'm not familiar with other manufactured types outside the U.S., but there's Arndt bronchial blocker and Cohen bronchial blocker. They come from different ranges, five French to seven French to nine French. If you don't have a large ET tube, let's say you got unlucky and the only ET tube somebody handed you was a 7.5, you may be able to get a 7 French bronchial blocker in that airway with quite a bit of difficulty. But again, there are different sizes to these bronchial blockers. How does this work? It's best to show this in picture. So, there's a connector, that adapter that comes with the blocker. It has four ways. One of them accommodates the ET tube. The other one accommodates the mechanical ventilation. One is for your bronchoscope and the other one is for your blocker. There's a tiny loop at the end of the blocker that can hook around your bronchoscope. You can secure it and then you can, with your bronchoscope, drag the blocker to the airway, the culprit airway that is bleeding, release the loop so your bronchoscope comes all the way on the top and you can inflate the balloon. Are you happy with where the balloon is? If you're happy, then you secure the blocker on the top. Now, this is a method that is very helpful for your patient. It's very helpful for your care, but again, if your ET tube is small, it takes a very long time to do this and a lot of troubleshooting. So again, large ET tube, just make that a practice. Have a large ET tube available in your bronchoscopy. So, 8.5, nine, but at least 8.5. All right, so here is just a cartoon of what we talked about, the blocker in the airway. One thing I want to point out is if you don't have a blocker, you can intubate on the left side if you're trying to protect the left from right. But if you intubate on the right side to protect right from left, keep in mind that your ET tube cuff often sits against the right upper lobe airway, and so your right upper lobe is also occluded, and so the only parts of the lung you're inflating are the right lower lung and the right middle lung. If your patient's already got bad lungs, that makes it a bit harder, so something to keep in mind. That's why the blocker would be helpful. What other bronchoscopy interventions? Iced saline lavage is one that we use quite frequently. I admit I use it very, very much. I think all of us do. Now, the reason we do that is all based on this one evidence from 1987 studying cold saline in 23 patients. That's it. But it worked. It worked for all of the patients. They instilled 50 aliquots of ice-cold saline, up to 750 ml. That's probably not what, well, that's not what I use, but it really helps. But it really helps manage your hemoptysis, at least temporarily, and buy you time to do what you need to do. In this study, none of the patients had to recur, come back to the hospital for management in three months, so that's a fairly successful three-month follow-up. Now, other bronchoscopic interventions. I never have epinephrine in my bronchoscopy suite, and if you do use it, and if you use it for minor hemoptysis or moderate hemoptysis, you need to be cautious. If you use it for massive hemoptysis, it's not going to be helpful. It's going to get diluted very quickly, and what other scenario is when you use epinephrine in the airway? If you don't have IV lines, and your patient has cardiac arrest, is coding, you put epinephrine through the ET tube. And so you could actually, you're in the rush of managing to take care of the hemoptysis. If you give too much epinephrine, you could actually cause arrhythmia in the patient, so I would recommend against it. Let's go over this pretty quickly. So this is a lady who was sent for biopsy, transbronchial biopsy, that's their biopsy, and here we go. So they started to bleed significantly. Here's a large clot. It's sort of a saddle clot. It's sitting in the trachea, including right and left main stem. We're trying to extract the clot from all of the airways. Here's the biopsy site. Do you want to suction this clot? You're all a dishonest crowd. Of course you want to suction, you're dying to suction it. The better question is, should you suction this clot? No, you shouldn't suction this clot. So your answer is correct. You should not suction this clot, no matter how badly you want to suction it. You should leave it alone. Now, the key question, and so this basically is a case gone bad, right? Because the patient got intubated and mended to the ICU. This was actually a cryo biopsy. So a couple of things to keep in mind, and I'm going to go through this very quickly because Dr. McRosty is going to do a beautiful job discussing what needs to be done in terms of management, in terms of different markers in the blood, in your labs, as well as your medicines, but a few techniques regarding transponkyl biopsies. So there are two school of thought. One is to keep your bronchoscope on the top of the airway and watch as soon as you remove a biopsy specimen and just watch for bleeding. Another one is to wedge your scope, and that's usually what I do. Whichever one that you do, you really have to make sure that you control the bleeding. So if you're entirely wedged and you still bleed, the thought is that you stay wedged for about three to five minutes and don't suction and just stay there. And if you still have bleeding, you may want to stay a bit longer. If you come back slowly and you still have bleeding, you may actually have to use flora to go back into that airway. So it's important to keep that in mind. Now, how many of you have used tranexamic acid? Wow, great. I pointed out that this talk has been happening for 10 years, and I have to say good and bad things. One, there's very few that has changed in it. One of the things is that we have one of the new faculty in our team is Dr. McGrosty, who has joined us since three years ago. But the bad thing about what's changed as little is that we haven't advanced so much in terms of science. So there is very little that has changed in this talk that I've been giving for 10 years, except a few slides on tranexamic acid. And so if we asked this 10 years ago, not many people would have, people would have not even known, lots of them, what is tranexamic acid. So two studies in this area, one of them has used IV, the other one has used nebulized tranexamic acid, both in the, for the case of hemoptysis. I would take, both are randomized control trials. I would be very careful about applying this to massive hemoptysis. So these patients, although were called massive hemoptysis, they actually were at least sub-massive hemoptysis. Their volumes, in order to be included in the study, their volume was a lot smaller than what you would consider massive hemoptysis. So regardless, I'll highlight one of these. 55 patients, 22 and 25 in each group, and they showed that placebo did far worse than tranexamic acid, and tranexamic acid actually kept the patients out of the hospital faster. It didn't really have significant change in terms of 30-day recurrence of hemoptysis or death, but had important value in terms of one-year follow-up. So important to keep in mind. The last study that I want to share with you, and this is actually fairly new, this came out in 2023. It's a study that has looked at IV versus nebulized tranexamic acid. What they did here was randomize 110 patients, so a respectable population here. A respectable population here. What they noted was that IV was actually inferior to nebulized tranexamic acid in all manners, in terms of six-hour follow-up, 12-hour follow-up, and 24-hour follow-up. So if you were to use tranexamic acid in your population, nebulized may actually be a better method than IV. So a brief summary of what we talked about. A couple of takeaway things. Turn your patient to their bad side down. Pick a large ET tube. Pick something over eight for sure. 8.5, perfect. Nine, excellent. A lot of this has to come with preparedness. So airway and hemoptysis drills are extremely important. And make sure that you have a multidisciplinary team around you. So call your surgeons early, call your IR doctor early, and make sure that the team that is around you is familiar with your patient. And with that, I think we're going to continue with the cases and then with the rest of the talks and then do our next questions. So our next speaker is Dr. Christina McCrosty. Dr. McCrosty is an assistant professor of medicine at UNC, at University of North Carolina, and she will be talking to us about the role of the medicines we use and their effect on hemoptysis and bleeding. Thank you. We're gonna take a break from acute management of hemoptysis to talk about prevention, which is a very important part of your systematic approach to hemoptysis. I have no relevant disclosures aside from shameless use of this Heavy Metal Bands logo. So again, massive hemoptysis requires a rapid assessment and intervention and a systematic approach to ensure timely management. So a key aspect is prevention and mitigating your periprocedural risk factors, including your patient factors, understanding the medications they take and planning your procedure carefully. So that's what we'll talk about today. Before I dive in, I just wanna talk a little bit about terminology. We've heard about the challenges with quantifying bleeding risk and quantifying hemoptysis. And what I found is when you walk into a patient room and the patient is coughing up blood, everyone is panicking. And so part of your job as sort of managing that situation is not only managing the patient, but managing the panic level in the room. And so I find that changing your vocabulary a little bit can help. And referring to the situation as a life-threatening hemoptysis event rather than massive hemoptysis can sort of help bring that panic level down from a 10, maybe to about a five, six, or seven, which is sometimes a little bit more helpful to get people kind of a little bit more into the moment. Either way, as we've heard, we know that just a small amount of blood can include the airways and it can severely impair oxygenation and ventilation. And so rapid intervention is key. I wanna point out, because we're talking about management of hemoptysis, I'm gonna focus on bronchoscopic procedures, but there are other procedures that can cause hemoptysis. So when you get called to evaluate a patient with life-threatening hemoptysis, you wanna make sure that if it's a procedural complication, it may not be a bronchoscopic procedure. For example, if a patient had an ultrasound-guided Seldinger technique pigtail chest tube and that was inadvertently placed into the parenchyma, this can cause bleeding into the airways and cause life-threatening hemoptysis. So just understand that there are other procedures that can cause this. I find it helpful to think about relative bleeding risk with bronchoscopic procedures. We know that there are some numbers associated with these and I'll review these, but I like to think of them in the context of low, moderate, and high risk in relation to each other when you're sort of thinking about your approach. And so I've organized this chart for you with increasing level of risk as you go down the chart. So you have airway inspection, bronchoalveolar lavage, endobronchial ultrasound-guided transbronchial needle aspiration, and peripheral needle aspiration. These are lower risk procedures which have a bleeding risk of around 1% depending on what literature you're reading. That risk goes up with endobronchial biopsy depending on the indication and the specific patient, and with transbronchial forceps biopsy with literature reporting up to 5% to 7%, sometimes a little bit higher range depending on what you're looking at. And you have a higher risk of procedural bleeding when you're talking about cryobiopsy procedures and therapeutic bronchoscopic procedures, interventional procedures. So with transbronchial cryobiopsy, your bleeding risk for mild to moderate bleeding has been reported around maybe about 22%, there's some variation in the literature. Overall bleeding risk is around 18% with that procedure. And then when you're talking about more interventional procedures, then your risk can be up to about 30%. So there's a wide variation there. And again, it's helpful to really understand the relative bleeding risk when you think about your procedural approach. Here's some pictures to help kind of solidify this. So the top left of your screen, you've got an endobronchial ultrasound picture of a needle aspiration of a lymph node. This is a 21-gauge needle. Below that, you have a robotic bronchoscopic guidance peripheral needle aspiration, again with a 21-gauge needle. You can see the catheter sort of highlighted in the white circle with your needle extended into the lesion, that's a cone beam CT image. But again, both of these are 21-gauge needle biopsies which carry a lower risk of procedural bleeding. Compare that to the pictures you see on the right side. So the top right is a mixed intrinsic extrinsic malignancy that has not yet been diagnosed that is impinging on this patient's trachea. So when you think about the diagnostic biopsy that you have to perform for that as well as the intervention, this is obviously gonna carry a higher bleeding risk than the small needle aspirations you see on the left. And then below that is a nice endobronchial carcinoid. You can see how vascular those can be. So when you're taking a biopsy sample of those, even if you're using a needle in the airway, you can have an increased risk of bleeding. And then in addition to that, whatever intervention needs to be done. So you can see the difference in risk there. It's just a nice illustration of that. So when you think about risk factors for bleeding, start with the patient. Think about their medical comorbidities. What sort of medical problems do they have that are gonna increase their risk of bleeding during a procedure? Do patients have a coagulopathy from liver disease or hereditary bleeding disorder? Do they have thrombocytopenia? Are they immunocompromised? Do they have a hematologic malignancy or medication that suppresses the immune system, or the bone marrow, excuse me, like chemotherapy or some other medications? Do they have renal disease with associated uremia? That's a little bit controversial, but there's a thought that there's some platelet dysfunction related bleeding risk with patients with renal disease. There's a theoretical risk of bleeding with transbronchial lung biopsy in pulmonary hypertension. This has been safely done in this patient population and arguably, nobody jump up about this, but there's also a risk of, or more of a risk with periprocedural sedation in this patient population, depending on the underlying cause of their pulmonary hypertension. But be aware of that risk as well as their bleeding risk. Tumors, malignancy, tend to be very vascular and carry an increased risk of bleeding. Infection as well, like we saw in previous presentations, you can have infectious aneurysms, you have a lot of inflammation associated with infection that increase your bleeding risk there as well. And like we've already heard, there are other conditions like bronchiectasis, you can have arteriovenous malformations that increase risk of bleeding. So it's important to have a really good understanding of what you're trying to biopsy before you actually biopsy it. You don't want to do a biopsy of an AVM, for example, because then we know that would not be a good situation. This is a non-inclusive list of medications that increase your bleeding risk. And I'll talk in a little bit more detail about aspirin in a bit. But in this context, I'm talking about higher doses of aspirin. Interesting, we've had a run of patients who have taken those headache powders that have high doses of aspirin. And we've had to reschedule some procedures with that because I don't have a lot of evidence about bleeding risk in that situation. But I'll talk a little bit more about aspirin in a moment. The other point I want to make here is the dosing of these medications, specifically the direct oral anticoagulants, can differ and the clearance of these medications can differ based on patient's renal function. So it's important to remember that as well. So one of the most important things you can do to prevent hemoptysis around a procedure is be very thoughtful about the procedure that you're doing. You want to have a good plan for the indication. You want to make sure that the biopsy that you're doing is actually indicated and that it's the right procedure for that patient and for that suspected condition. You want to make sure that you're discussing that risk with the patient. You're talking about the potential benefits and you're talking about potential alternatives. The good news is this is all part of your informed consent process, so I'm not adding any work to your workflow. But it's important to keep this in mind. When you're evaluating patients before a procedure, in addition to your usual history and physical exam, I highly recommend focusing on their medication list. We all use electronic medical records and the medication lists are usually not up to date, right? So it's really important to confirm with the patient and their caregiver that they don't take any blood thinners. And I usually will just take another 10 seconds and just list the most common ones. I've occasionally had a patient pipe up and be like, oh, I take a Pixaban. I didn't know that was a blood thinner. So it's really helpful to go through that in detail with the patients just to confirm because it can really affect your procedural bleeding risk. Routine lab tests prior to bronchoscopy are not always necessary. It really depends on your clinical judgment and your suspicion of risk for a bleeding problem. For example, if a patient has liver disease and you suspect they may have a coagulopathy, definitely go and look for that. If they're getting chemotherapy and you wanna make sure that they don't have thrombocytopenia or some other issue, then definitely go and look for that. If they have renal disease and you're worried about uremia, do some lab work. So this is very much based on your clinical judgment. You don't, in a sort of normal healthy patient, you don't have to do any pre-procedural lab tests usually. Another very important component of this is discussion with your team. You wanna talk with everybody that's in the procedure room with you, whether that's a bronchoscopy suite, the ICU, the OR. You wanna talk to the team that's working with you about what the procedure risk is, what procedure you're doing, and what you plan to do when you run into bleeding. If you do enough procedures, you're gonna have some bleeding. And it's important to know how to manage that and it's important to communicate with your team. If you're doing a higher risk procedure, then I strongly recommend discussing if you may need some additional help controlling bleeding, discuss with your subspecialty teams that might need to help support you. So whether that's interventional pulmonary, thoracic surgery, interventional radiology, have that discussion beforehand and make sure that people are available and aware of the patient and aware of that risk. There's really no, there's not great data around platelet thresholds for procedures. The generally accepted threshold for bronchoalveolar lavage is a platelet count of 20,000. This varies pretty significantly based on comfort level. Some people are comfortable doing this with a little bit lower threshold and some higher. Around 50,000 is a generally accepted threshold for transbronchial forceps biopsy. There's also no accepted threshold of BUN for patients with renal disease. Again, there's this theoretical risk of increased bleeding time from uremia-associated platelet dysfunction. And some people recommend giving desmopressin within about 30 minutes of the procedure. My opinion, and this is just opinion, is it's a pretty low-risk intervention that could be helpful. So there's not much harm to it, generally speaking. I don't know what y'all's practice is. Same? Okay. Just a word on a couple of common concerns on a couple of commonly performed procedures. So talking about transbronchial forceps biopsy, the key is to optimize your yield. And what I mean by that is make sure that you're sampling the part of the lung that's affected by whatever you're looking for. So, and I'll give you a picture in a moment to demonstrate this. But if you're biopsying a part of the lung that's not affected, then your yield is gonna be very low. Your pretest probability of getting an answer is gonna be low, and you're putting a patient at increased risk, really for not a great reason. So make sure that you're sampling an area of the lung that's involved by whatever process you're looking at. If possible, attain biopsies from the dependent portion of the lung. Let gravity help you if the patient does have bleeding. You're gonna have less soiling of different parts of the lung. If you have bleeding, it's gonna fall into those dependent portions. Sometimes it's easier to wedge your scope into that area of the lung as well. It's not always possible, but if at all, you know, if you have diffuse involvement, sometimes it's easier to do biopsies from the dependent portion. Make sure that you're prepared when you do see bleeding. Have all of your tools in place. Be very familiar with your algorithm for dealing with periprocedural bleeding, and Dr. Lamb will talk about that in a moment. But make sure you have everything available. Have ice-cold saline on your bronchoscopy cart for every procedure. It's really not ideal if you have bleeding and you're scrambling to find a bag of frozen saline. If you do use epinephrine, make sure it's available. Make sure that you know the dilution and that you appropriately dilute it. I don't use it very often because it's, I find it doesn't work very well and has a lot of side effects. But if you use it, you know, make sure you're being smart about it. If you're doing a higher-risk procedure, then it's usually wise to have your sort of more advanced backup tools available, like bronchial blockers. If not in the room, then very accessible. And have someone in the room that knows exactly where to go to get it if it's needed. A word about transbronchial cryobiopsy. This really is better performed by experienced bronchoscopists under an established protocol with a stable airway, either a rigid bronchoscope or an ET tube like we've discussed. Please excuse my typo. Use the smallest cryoprobe that you can. The smallest one's not actually 1.9 millimeters. It's 1.1 millimeters. And then consider use of a bronchial blocker during the procedure. Again, using an established protocol with a proceduralist who's comfortable and experienced in that procedure. So this is a picture to sort of reinforce the idea that you want to optimize your yield by choosing the affected portion of the lung. So in the picture on the left, you can see that the patient has upper lobe predominant disease. And so you're going to get a better yield if you sample that area. You're not going to sample the lower lobe in that patient because you're unlikely to get an answer. And you're putting that patient at risk for really not a good reason. The picture on the right side of the screen, the patient has a left lower lobe lesion that we're interested in. So that's where you're going to target your biopsy to hopefully get an answer and not, you know, not miss a diagnosis. So let me talk about aspirin a little bit. I want to talk about patients who take 81 milligram or low dose aspirin. The most common indication for those is coronary artery disease and peripheral vascular disease. And actually, if you hold low dose aspirin in a patient that has coronary artery disease, particularly if they've recently had stenting of their coronary arteries, you can actually have an increased risk of cardiac events peri-procedurally. So usually we can continue this medication. There's really not an increased risk of bleeding associated with it. And so it's safer to continue. You can have risks like, or complications like instant thrombosis in patients with peripheral vascular disease, especially if they've had recent surgeries. You can risk limb ischemia. So it's very important to have conversations with the teams that are managing these medications before holding them. So when we're talking about clopidogrel, ticagrelor and prezegrel, then definitely have conversations with the teams managing those medications. Sometimes dual antiplatelet therapy is required for a certain amount of time, you know, for coronary artery stents. And depending on the stent, you may be able to hold it sooner than you think. So definitely communicate well with your teams. For heparin formulations, here's another chart with some recommendations on when to stop and restart these medications. I'm particularly talking about therapeutic dosing. And these can vary a little bit depending on indications and underlying medical problems. But we don't typically hold prophylactic dosing for most bronchoscopic procedures, even interventional procedures. I don't know if you guys have the same practice. Because there's not really an increased bleeding risk in that situation with low-dose prophylaxis. And then let's talk about other anticoagulants. So again, recommendations for stopping and restarting, general information, especially with the direct oral anticoagulants, this can vary a bit based on renal function. But there's a wide range of indications for these medications. So we can see it for atrial fibrillation, venothromboembolic disease, heart valve prostheses. So it's really important to communicate with the teams that are managing those conditions on safety of holding these medications. Some of those patients will need bridging in order to safely hold anticoagulation. And so please communicate with your other teams. And then here is a list, I'm not gonna go through it in detail, of reversal agents for various anticoagulants. Not all of these are gonna be available at every hospital. So it's important to know what your options are, look at your facility's list of medications, and see what's available to you, so that you really have a good understanding of your resources when we're talking about bleeding risk around anticoagulation. So our take-home points for prevention of hemoptysis is know the relative bleeding risk for the procedures that you're doing, and very carefully consider the procedures that you're doing, and have a thoughtful approach to them. Discuss with the patients the risks, the benefits, and the alternatives. Know the patient factors that may increase bleeding risk, know the medications that may increase bleeding risk, and understand the pharmacology and the risks of those anticoagulants and antiplatelet agents. And finally, I didn't put that up here, but I should. Communication and discussion with not only your team doing the procedure with you, but also the teams that are co-managing the patients is key in preventing hemoptysis around procedures. Thank you. All right, great, so we're gonna bring it home in these last few minutes, and hopefully tie some things together, and I really wanna let this part be an emphasis on team training and creating team insight, and how to do that and sustain it at your own institution. And then I'm gonna highlight the nuances of interventional radiology's role, which is significant in these cases most often, and then the role for a surgical intervention. And give you kind of an algorithm to work with. I have no disclosures. And I'm gonna focus on the systematic approach, and really hope that everyone comes away today thinking of this like an airway code. We're very algorithmic when it comes to ACLS. This should be no different. It probably enhances your likelihood of success as your team training as well. This is something I created many years ago, and I've added to it over the years. It's small, and I apologize for that. You can take it and then blow it up. But I'll drill down all the key elements. And throughout the course of all the presentations, you've seen layers of this, and I'm just putting it all together. And it's just ways of algorithmically thinking about integration of how you're doing a lot of things simultaneously. And I can't stress enough the importance of alerting other stakeholders. You're not an island. Yes, you have a bronchoscope, and there's a lot of upfront work you can do, which is vital, but you need to, this is when you phone not only one friend, you phone friends, and have an algorithm where you all feel comfortable in chaos so that you can actually work through the algorithm together. So I use the term often, airway code and team training. And on a practical note, we've created a team training session. We do it at least twice a year, and we integrate our fellows, our respiratory therapist, our senior attendings, critical care and pulmonary, as well as our fellows. And I have to say, one thing that we've noted anecdotally is when fellows have become in hands-on training with how to use the gear, they often are making the biggest impact at bedside, because they're oftentimes the first one to get to the scene, if you know what I mean. So let me spend a little time on this slide. So ABCs, it sounds obvious, but you've heard about airway, breathing, circulation. Just know that imminently, this is a difficult airway, and it accelerates in seconds. So you have to make sure you have the tools, and you're able to have practiced it and done dress rehearsals so that when you're nervous and your palms are sweating, I have a laminated cart on my travel cart that actually says, hey, dummy, here's the steps. So if anyone gets nervous and it's in the middle of the night you can, someone can call up those steps to you. Because I'll guarantee when you crack open the package of either of the commercially available blockers, the fine print is fine print. And it's hard to read those instructions, trust me on that. I know, and that's why I changed our algorithm in terms of what we have in our laminated cartons. And it's washable, you can wash it off and keep it going for next time. So the other thing is, I can't stress enough the endotracheal tube size. Don't box yourself in, in terms of at a minimum of an eight, ideally a nine if you can accommodate that. On average, if you're talking blocker of either brand, the workhorse of blockers, and sometimes there have been shortages of blockers from manufacturing. Make sure you know where those blockers are located. Are they central supply? Are they in your Bronx suite? Are they in your ICU? We stock at least two of each. Heaven forbid something fall on the floor and you just have one tool. Always have a backup. Your seven French will often be your biggest workhorse and most practical of either of the devices. The blockers. Can't stress enough either the bad side down. Sometimes while you're working to get the blocker in, folks, the patient migrates back on their back and they're still bleeding. And then you've got spillage into the good lung and you're already seeing the SATs drop and then you've got a bigger issue. I do think that I've used in my practice more and more topical transexamic acid, 500 to 1,000 milligrams, no more. There's probably actually no derived benefit from adding more. At least there's no study to compel us to do that. But it can be utilized and make sure you have access to it and keep it handy. If you can't call for it from the pharmacy in crisis, it will take too long. You have to have it stocked in your Bronx suite, for example, things like that. Ice saline. Let's talk a little bit about the multidisciplinary team. Not every team member has to get called, but you definitely wanna have on speed dial your intensivist, your interventional radiologist, and give them that information that you think you've narrowed it down on which side it's on. Really helps them streamline their process and get to the meat of the matter quicker. And then thoracic surgery, if it comes to that. Sometimes ENT, don't forget, sometimes nosebleeds can, believe it or not, mimic massive hemoptysis elsewhere. So don't get too cocky. Question what you think you know and try to verify it. So you've already heard different things. ECMO, we're in the ECMO era more than ever. You will get called more than ever now for hemoptysis, and I'm not talking minor, I'm talking major. And there are algorithms that are published that really highlight, I mean, while the patient's on ECMO, they're anticoagulated. But there are case-based scenarios where you have to at least temporarily hold the heparin in order to stop the bleeding and localize. We could actually create a viable airway when it's bilaterally, it's already kind of flowed over. I've gone into airways for the whole trachea, main stem bronchi, completely obliterated with clot, and the bleeding will not stop. And you have to have a shared conversation with your ECMO team and providers on that front. I highlight the vascular anomalies because more times than not, those may likely require a surgical rescue. A surgical rescue. But you're trying to put the finger in the diacon triage as much as you can, but their mortalities are certainly gonna be higher. But there's a lot that your IR team can do to embolize. You'd be surprised. They can't embolize the entire pulmonary trunk. They cannot do that. And believe me, sometimes you want to ask them to, but it's really not what they, that's not the point. It's really not advisable, and they won't be able to, and they won't do it, they just won't do it. Are there any interventional radiologists here? I absolutely love our interventional radiologists. I mean, you definitely wanna have a conversation. I'm gonna highlight something. Actually, I'm gonna use this opportunity here to say this. After you've gone down for the embolization, you wanna either be down there in the lab and see it happen, or you wanna call the radiologist afterward and say, hey, how do you think it went? Do you feel like you got the bleeder? And they will give you a very candid outlook on that, because then you can predict if there's a high likelihood of recurrence that could be significant in the impending 24 to 48 hours. Very key. This is just a study that breaks down, published in 2010, but not a lot has changed. Just showing that bronchial artery embolization is enormously effective, and it's only gotten better as the technology and the savviness of our interventional radiologists has grown over the last decade or so. So let's dig into that a little bit. I'm not an interventional radiologist, right? I'm an interventional pulmonologist, but I think it's important for us to be clear on what not only the interventional radiologists can do, but at your own institution. That's probably the most important when it comes down to it. What are your capabilities and your surgical support when you need it? So let's just hit a question here. This will be kind of a shout out the answer, but what do you think is the truest, or the true statement for BAE, bronchial artery embolization? A, bronch is not necessary. A CTA should be able to help you localize in most of the cases anyway. B, BAE should not be repeated due to increased risk of complications. C, the overall increased success rate of BAE is greater than 75%. Or D, spinal cord ischemia from a BAE complication is approximately 10%. How many think it's A? How about B? How about C? Gotcha. How about D? Okay, let's talk about it. So actually it's quite effective. In some experienced hands, you might see 75 to 85% in the published literature quoting success. Depends on the differences of the case and what the risk factors are, so it's gonna be variable. And then I'll highlight that the spinal cord ischemia, that's a devastating complication, but it's rare. We're talking 1.4 to 6.5%, paralysis in 1%. But it is important to note that. All right, so I'm gonna tell you a little bit. I've got the inside scoop, because I've talked to our interventional radiologist. So what do they actually do with that CTA? It's not the same as when you're looking for a GI bleed. You're looking for extravasation for GI, but for the pulmonary CTA, you're not looking for extravasation. You're just looking for, are there vascularity, is there hypervascularity, is there tortuosity? You're trying to get a lay of the land, a roadmap of the vessels in play. You're not looking for extravasation. So you don't have to have active bleeding to identify what they may go for as targets. And so they'll use all that information. A CTA isn't mandatory, but it can be extremely helpful. And this, I'm sorry, let me go back. I saw some people trying to take a pic. But this tells you all the things they're looking for. They're not looking just for the bronchial artery, which nine times out of 10 will be the smoking gun off the aorta. But it will be intercostals, aberrant vessels in the subclavian and elsewhere. So I've already kind of highlighted that. I think that, again, nine times out of 10, bronchial artery circulation. And sometimes, if you have a tumor causing the impetus for the bleeding, they will identify the blood vessels a priori that are feeding into that and just empirically embolize those vessels. I think that's what often happens. This is just a little anatomy, how the bronchial arteries come off. And there's a handout shared with all the folks who are attending. These are all on that, so don't worry about this too much. Technique, I'm just highlighting again. They will shoot an aortagram of the thoracic aorta. They're looking to see for offshoots for the spinal artery. They're just looking to see where it is so they can try very meticulously to avoid that. This is just, again, part of, so what kind of embolization tools? I'd say nine times out of 10, they're using either gel foam or now the polyvinyl alcohol particles. They're ranging in sizes and they're very, I won't say easy, but they're more facile to get them where you want when you have very small takeoff points of your arteries. And there's tortuosity. Also, I would give you a nuance that coils can sometimes be used in the older patient where you're looking for permanency, where if you have a 25-year-old who is bleeding, maybe you want to put the finger in the dike for the moment, but you don't want to wipe out by infarcting that lung for the long haul. And that's case by case, but just something to think about. And the radiologists are usually savvy. They're savvy in thinking about that. And they use that as guidance for themselves. Just so you'd know that there's other arteries that can contribute to the bleeding, and they will sometimes empirically look for intercostals that feed a tumor, for example, in addition to the bronchial artery. All right, coming around the homestretch here. So we look at the bronchial artery aberrancies. 20% will be aberrant. They'll come off in different locations. They'll come off any of these other arterial trunks. So they'll look for the obvious and then they'll look for the more challenging nuances. Just know that that can happen. I think that I've highlighted, I'll just highlight here, particle size, tortuosity of vessel, and just a little snapshot of a potpourri of the different tools. And I just think it's important to know that more times than not, they're moving more toward the particles because of the nature. They're easily accessible. And then the coils are still kind of a tried and true. And I'm just gonna walk you through a few cases very briefly. Glue and gel foam, while they're available, they're not really the top two used devices or technologies. Very successful. But don't be afraid to ask for a second round if the patient rebleeds significantly. It's worth going back. And your radiology conversation after the first makes it more viable to think, okay, it's worth going back. And even if they say they got it, I still have the conversation if the patient significantly bleeds. And I leave the blocker in at least 24 hours post the first embolization. And I do it under visual guidance before I take the balloon down. All right. Possible complications. Spinal artery ischemia, that's the big one I mentioned. But there's many other things. Fever, pulmonary infarction happens. They can have a little bit of post-treatment hemoptysis that makes you nervous as the bronchoscopist, but it's not unusual for that to happen. Not unusual. This again highlights a few other things. I'm gonna go through some cases. Here's a little anatomy lesson regarding where the spinal artery, they may come off. There's two particular locations and two different types. Radiologists are very savvy with that. Here's some cases where bronchiectasis, TB and bronchiectasis, this is actually a case of ours. They localized a very hypervascular tortuous and dilated vessel. They were able to put coils in just by the size of the abnormality. And then the patient had multiple coils. And then two years later, came back with a recurrent bleed. This is a patient, you might even have the conversation, could they tolerate a focal resection of that bronchiectatic lobe? And that's a conversation to have. This patient wasn't not a candidate for that. They re-bled. They got coiled two years later successfully. You can use a combination, although you can't see the glue as readily here. You see the coils more often. And then surgical indications, just to wrap up. So mortality's gonna be high. By the time you phoned all those friends and every friend has done something and you're still bleeding, it's just a harbinger for a poor, poor prognosis because what you have left, those patients are probably not more stable. To have the conversation in an ideal world for the surgeons that you've stabilized, you put the finger in the dike, you've got the saved airway, and now they can kind of, not leisurely, but methodically go and think about operative options. And I think the big ones are aspergillomas. That may be the indication for a surgical resection. Really focal lobar bronchiectasis are probably the top two. And some of these vascular traumas from iatrogenicity. And I'll wrap up with this. These are some of the options, but I think we've come a long way since the 1940s. Mortality, even in the surgical arena, when we get down to that level, the mortality's still far more, significantly reduced, I should say, because the radiologists have really been the stopgap. Majority of patients can be managed and definitively managed with interventional radiology embolization. So I think those are the take home. So I'd wrap up saying airway code. Train your mindset and your team to airway code. Do drills twice a year. Do it not just talking about it, but get down there in your sim lab and get in there and get your hands involved with the management and use of those different blockers and know what you have in your own institution, that you have a ready supply so you're never left stranded without a tool that you need. And I'm gonna wrap up with a few things. There's simulation hands-on, on hemoptysis and all the blockers. I don't know if the sessions are filled yet, but if they're not, check out. We have classes at Cheston, Chicago all year round and always here at the annual meeting. If you didn't make it this year to that, sign up for next year. We have room for you. And then please evaluate all of us in this session so we can only hopefully make it better and make it really a dynamic and living presentation that will always suit needs. Because believe me, I'd be lying to you if I said I don't get nervous. I mean, with all this and some experience, the hair on the back of your neck, you're gonna be sweaty. Your palms get sweaty, but at least you know. And if you build redundancy with your team, then you have backup. You're never alone. You're never alone. So with that, I'll wrap up. And I guess questions, if we have time for questions? Yes, I think definitely. Yeah, thank you. Thank you.

massive hemoptysis

hemoptysis management

causes of hemoptysis

bronchoscopy

bronchial blockers

bleeding control

preparedness in healthcare

multidisciplinary teamwork

risk levels of procedures

interventional radiology