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 Rasmussens).

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,
Kartageners)

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.

MASSIVE HEMOPTYSIS
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
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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 lavage
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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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