This week’s case highlights the presentation of a 14 yo M with stable asymptomatic hypoxia. Fellows noted that polycythemia on the initial CBC could be secondary to chronic hypoxia. CXR appeared overexpanded with air bronchograms with possible small RLL consolidation and prominent hilum L>R with asymmetric vasculature. Fellows brought up if his pulse ox had ever been checked before. The pediatrician had checked at a prior WCC and noted it to be low, but had contributed it to a bad sample due to cold extremities as the patient was asymptomatic at the time. The case pointed towards chronic hypoxia from an unknown cause, possibly from some form of cardiopulmonary shunting (ie congenital cardiac disease, AVM, bronchiectasis), prompting additional workup with a CTA.

CTA Chest showed:
1. Negative for pulmonary embolus.
2. Right lower lobe pneumonia. Enlarged right hilar lymph nodes may be reactive.
3. Suspected left upper lobe arteriovenous malformation. No surrounding parenchymal changes suggestive of bleed

The patient was admitted to the PICU where the general surgery team, cardiology, and IR were consulted. CTA head was obtained and negative for AVM. Cross-sectional MRA of the abdomen to evaluate for liver AVM was also negative. The patient and his family were educated on arterial venous malformations, which is not a life-threatening diagnosis. In other areas of the body, they are high-flowing, however, in the lungs the pulmonary artery is not a high-flowing blood vessel. IR recommended the patient undergo intervention while the size of the AVM is manageable because if the AVM continues to grow, there is a higher risk of bleeding. Coil embolization was discussed. The patient was discharged from PICU with O2 saturations in mid-80’s. Pediatric cardiology noted that the patient’s hypoxia is chronic and he does not need to be on home oxygen. He underwent coil embolization of a giant pulmonary arteriovenous malformation in the left lung with IR. His O2 saturations have been 98% post-procedure and his acral cyanosis completely resolved.

Now if he re-presented with hemoptysis and acute decompensation, what important consideration should you take? Given his known left AVM, when intubating you should attempt to right main stem given likely pulmonary hemorrhage into the left lung.