Massive Hemoptysis

Massive Hemoptysis

Defined as expectoration of blood exceeding 100 to 600 mL over a 24-hour period.

Only 5% of hemoptysis is massive but mortality is 80%.

Massive Hemoptysis

Must r/o non-pulmonary causes– upper airway or gastrointestinal tract

Alkaline pH, foaminess, or the presence of pus may sometimes suggest the lungs as the primary source of bleeding

Initial approach to the patient is dictated by the clinical presentation. How sick is the patient? Patients with rapid bleeding or decompensation need

ACLS first and control of their bleeding. Secondary goals are determining the site and

cause of the bleeding and whether or not the patient is a surgical candidate.

History

Prior lung, cardiac, or renal disease? History of cigarette smoking? Prior hemoptysis, other pulmonary

symptoms, or infectious symptoms? Family history of hemoptysis or brain

aneurysms (suggesting hereditary hemorrhagic telangiectasia)?

History

Exposure to asbestos, trimellitic anhydride or other organic chemicals?

Patient's travel history? History of bleeding disorders or use of ASA,

NSAIDS, or anticoagulants? History of upper airway or upper

gastrointestinal complaints or diseases?

Physical Exam

Telangiectasias -- hereditary hemorrhagic telangiectasia.

Skin rash -- vasculitis, systemic lupus erythematosus, fat embolism, or infective endocarditis.

Splinter hemorrhages -- endocarditis or vasculitis. Clubbing is nonspecific, since it can occur in

many chronic lung diseases.

Physical Exam

Audible chest bruit or murmur that increases with inspiration -- large pulmonary AV malformations .

Cardiac murmurs -- congenital heart disease, endocarditis with septic emboli, or mitral stenosis.

Legs should be examined carefully for possible deep venous thrombi.

Causes of hemoptysis

90 % of cases are due to: TB Bronchiectasis Lung abscesses

Tuberculosis

Active cavitary or noncavitary lung disease can cause small or large amounts of bleeding.

Most of these patients have sputum smears that stain positively for acid-fast bacilli.

Tuberculosis

Sudden rupture of a Rasmussen's aneurysm

Inactive TB can cause bleeding due to residual bronchiectasis, erosion of a broncholith through a vessel and into an airway, or by a cavity that subsequently acquires a mycetoma.

The source of bleeding in each of these causes is usually the bronchial arterial circulation (except Rasmussen’s).

Bronchiectasis

Chronic airway inflammation that causes hypertrophy and tortuosity of the bronchial arteries

Accompanies the regional bronchial trees with expansion of the submucosal and peribronchial plexus of vessels.

This circulation is under systemic blood pressure, so that rupture of either the tortuous vessels or the capillary plexus causes rapid bleeding.

Bronchiectasis

Results from prior infection (bacterial or viral), cystic fibrosis, TB, or impairment of the mucociliary clearance apparatus (PCD, Kartagener’s)

Infections

Bleeding may occur acutely from necrosis of lung tissue or from rupture of hypertrophied bronchial arteries in the setting of chronic inflammation.

Hemoptysis occurs in 50 to 90 percent of patients with aspergilloma

Parasitic infections are a very common cause of hemoptysis Paragonimiasis in Southeast Asia. Severe leptospirosis may be complicated by massive

alveolar bleeding and hemoptysis

Lung Cancer

Bronchogenic carcinoma usually causes nonmassive hemoptysis.

Hemoptysis occurs at presentation in 7 to 10% of patients.

Hemoptysis occurs during the disease course in approximately 20%.

Immunologic Lung Disease

Goodpasture's syndrome Wegener's granulomatosis Systemic lupus erythematosus (SLE) Idiopathic pulmonary hemosiderosis. Pathologically, many of these diseases have

components of pulmonary capillaritis

Management and its Difficulties

Multitude of potential etiologies. Course of bleeding is unpredictable. It is frightening to see patients dying from

asphyxiation, even in spite of intubation. There is no consensus regarding the optimal

management of these patients.

Management

Adequate airway protection, ventilation, and cardiovascular function

Intubate if pt. has poor gas exchange, rapid ongoing hemoptysis, hemodynamic instability, or severe shortness of breath

Reverse coagulation disorders CT Surgery Consult +/- VIR

Management

A major priority in the acute management in protection of the nonbleeding lung.

Spillage of blood into the non-bleeding lung can either block the airway with clot or fill the alveoli and prevent gas exchange.

Need to know site of bleeding!!!

Protection of nonbleeding lung

Place bleeding lung in the dependant position Selectiely intubate the nonbleeding lung- easiest if

you want to intubate right mainstem brochus during a left lung bleed.

Risk = blocking RUL bronchus

Balloon tamponade via bronchoscopy Placement of a double lumen ETT specially designed

for selective intubation of the right or left mainstem bronchi

Used as a last option in an asphyxiating pt.

Management with Bronchoscopy

There are no controlled trials in bronchoscopic techniques used to slow or stop bleeding

Lavage with iced saline and application of topical epinephrine (1:20,000), vasopressin, thrombin, or a fibrinogen-thrombin combination.

Management with Arterial Embolization

Used as a semi-definitive treatment option or a bridge to elective surgery.

85% of the time the bleeding stops after embolization

10-20% of patietns rebleed in the following 6-12 months.

Management with Surgery

Patients with lateralized, uncontrollable bleeding should be assessed early.

Usual assessment includes pulmonary function tests, but often these patients are too ill for physiologic testing

Relative contraindications to surgery are: severe underlying pulmonary disease, active TB, cystic fibrosis, multiple AVMs, multifocal bronchiectasis, and diffuse alveolar hemorrhage.

Morbidity

Comparison of medical and surgical treatment for massive hemoptysis favors surgery as having a much lower mortality.

Highest risk patients were not considered to be surgical candidates and were managed medically.

Reports from the 1980s suggest that the mortality rates are approximately comparable in patients who qualified as surgical candidates.

However, medically treated patients probably have a higher risk of rebleeding within the first six months.

Stabilization:

Ensure adequate ventilation and perfusion Avoid asphyxiation Lateral decubitus position Administer oxygen Patients with poor gas exchange, rapid ongoing

hemoptysis, hemodynamic instability, or severe shortness of breath should be orally intubated with a large bore endotracheal tube

Monitor BP, pulse rate, respiratory rate and urine output

MASSIVE HEMOPTYSIS

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Large IV access + Fluid resuscitation Blood transfusions Cough-suppressing drugs can be added, but

they may favor the hazard of blood retention in to lungs.

Coagulation disorders should be rapidly reversed

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Protection of non-bleeding lung: Place bleeding lung in dependant position- lateral

decubitus ( if origin of bleed is known and limited to 1 lung) Prevent contamination of good lung

Selectively intubate the nonbleeding lung with bronchoscopic guidance ( isolate rt. and lt. mainstem bronchi)

Placement of a double lumen ETT specially designed for selective intubation of the right or left mainstem bronchi

Emergency bronchoscopy – cold saline lavagepgmedicalworld.com

Endobronchial tamponade: Balloon catheter is introduced via

bronchoscopy and inflated to occlude the bronchus(prevents aspiration of blood into unaffected areas and also stops the bleeding)

The balloon is left inflated for 24 to 48 hours, and the patient is then observed for rebleeding with the balloon deflated for several hours

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Bronchial arterial embolization:

Angiography should be performed initially Vessel proximal to bleeding site is cannulated and

material like gelfoam – injected to occlude the vessel Used as a semi-definitive treatment option or a

bridge to elective surgery. 85% of the time the bleeding stops after

embolization 10-20% of patients rebleed in the following 6-12

months Complication: embolization of the spinal artery

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Other methods to control bleeding:

Phototherapy Electrocautery Argon plasma coagulation Nd-YAG laser

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SURGICAL MANAGEMENT

Done in pts. with uncontrolled life-threatening hemoptysis or localized disease subject to recurrent bleeding

Resection of bleeding lobe or lung maybe done

Relative contraindications to surgery are: severe underlying pulmonary disease, active TB, cystic fibrosis, multiple AVMs, multifocal bronchiectasis, and diffuse alveolar hemorrhage.

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RECOMMENDATIONS

First, stabilize the patient and then perform early bronchoscopy along with other appropriate diagnostic studies

If the patient continues to bleed aggressively, arteriography is most reasonable for localization and therapy

If bleeding persists despite embolization or if the patient is too ill to go to angiography, then blockade therapy or a double lumen tube should be considered

While surgery remains the only truly definitive therapy, it should not be used in the acute emergent setting unless it cannot be avoided

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