Great discussion. Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations:
Call for help: Patients with massive pulmonary hemorrhage die. Respect hemoptysisespecially related to tumors or scenarios where there is an erosion into a vessel. They're ok until they're not and then its often too late,
Send someone to the chart/x-ray to get info as to which side the pathology is on
Raising the bed will help allow you to lift the epiglottis out of the pool of blood and see it more easily.
Hope that the disease is on the left. If you know this use a bougie and 1/4 turn to the right once (if) you feel clicks and place gently until holdup then go ahead with a BFT. As per the study quoted in this piece we have been able to consistently cannulate the bronchus of choice using a bougie in cadavers.
If you are not sure of the side they are bleeding from then we would suggest a poor man's isolation technique using a 7.0 ETT and intubating the RM bronchus either with or without a bougie. The left side can then be accessed with a bougie again by a 1/4 turn to the left once in the trachea and advancing until gentle hold up at ~30 cm and placing a second 7.0 ETT. Yes I know that a bronch won't like these tubes but otherwise there is no opportunity for subsequent therapy as the patient drowns. It's an awful death. You can block the offending side with a foley.
If bleeding is too much and SALAD etc approach fails… these patients die. One device that will be returning to the market developed here in Halifax is the lightwand and its the only device out there that will consistently be successful in a soiled airway…. IF YOU HAVE IT AND IF YOU HAVE EXPERIENCE WITH IT which most don't. It has saved my ass numerous times.
If you can't see from above then FONA is indicated use a small ETT 5.0 and push it too hilt will usually go to RM bronchus. You will either be able to oxygenate or divert blood so now you can put a second tube in if necessary from above. Used a 5.0 ETT because takes up less real estate for second tube to pass from above.
When your consultant comes down and complains about the size of tubes that are in place resist telling them to fuck off.