Massive Hemoptysis

Best Review of Massive Hemoptysis Dx and Rx

Causes

bleeding from the bronchial rather than the pulmonary circulation causes ~88% of hemoptysis.

Bronchitis

rarely the cause for massive, but most common cause of submassive hemoptysis

dilated bronchial arteries erode during inflammation of airways

always consider lung ca in patients with bronchitis from smoking

Lung Cancer

most common with squamous

Bronchiectasis

abnormal dilation of the bronchi with altered mucociliary clearance, persistent bacterial colonization, chronic inflammation, and submucosal neovascularization. Cover with broad spectrum antibiotics. Cystic Fibrosis has similar pathology and can result in massive bleeding. In this case directed therapy against pseudomonas should be initiated use antipseudomonal penicillin with aminoglycoside.

Tuberculosis

complicates ~25% cases. Often caused by a Rasmussen’s aneurysm, a small outpouching of the pulmonary vasculature within a cavity wall. TB can also result in bronchiectasis and antibiotics are needed if this is the cause of the hemoptysis.

Lung Abscess

anaerobic abscesses in areas of aspiration

Other Pulmonary Infections

massive hemoptysis is only seen with tissue necrosis such as with anaerobic, staphylococcal, and actinomycotic infections. Septic pulmonary embolisms can also trigger bleeding. Invasive aspergillus can be found in COPD patients as well as neutropenic patients. Pulmonary mucormycosis and the other fungal pathogens are also occasionally responsible.

Pulmonary Embolism

as mentioned especially in septic emboli, but any clot can cause bleeding

Less Common:

Aspergillus Fungus Balls

can complicate TB and sarcoidosis

Catamenial Hemoptysis

with the onset of menses, from aberrant endometrial tissue

Rasmussen’s aneurysm

common in TB pts

pulmonary vessel ruptures into cavitary lesion

Diffuse Alveolar Hemorrhage

multiple causes, but if also renal problems, significantly narrowed differential

may need high dose steroids (Solumedrol 1-2 grams)

Immunologic Lung Disease

Goodpasture’s

Antibasement Membrane Disease

pulmonary hemorrhage and renal disease

after stabilization, need steroids and immunosuppresion

SLE

Wegener’s Granulomatosis

c-ANCA is 97% specific and 85% sensitive

Idiopathic Pulmonary Hemosiderosis

Immunocompromise

complicates autologous bone marrow transplantation

post transplant

Bleeding Diathesis

Drug Induced

from crack cocaine

Vascular Abnormalities

Aortobronchial

Pulmonary Artery Aneurysms

Arteriovenous Malformations

Trauma

Iatrogenic

catheters and bronchoscopes

Diagnosis

localization is first priority

Get C-XR

May need radionuclide studies or chest ct

Bronchoscopy is the best single test to localize the source of bleeding

Management

150-200 cc can fill a large portion of the bronchial tree

>600 cc in <4 hours associated with huge jump in mortality (71%)

Use the largest possible ET tube

If selective intubation is necessary, remember that right lung intubation will also cut off the right upper lobe To facilitate left lung intubation, place the patient in right lateral decubitus and curving the tube to the left.

Double lumen tubes may be used if available

Endobronchial tamponade with balloon catheters

place the patient with the bleeding lung dependant

If bleeding stops spontaneously, the patient may be managed expectantly. Give cough suppression with codeine

Laser photocoagulation can be used as well as endobronchial infusion fibrinogen-thrombin.

Bronchial artery embolization now is the first step for persistent bleeds be used it was risky with destruction of patency of spinal arteries, but new selective techniques make it fairly safe.

The final step is surgical resection

Management of Massive Hemoptysis Massive hemoptysis is variably defined as expectoration of blood > 100 – 600 mL over 24 hours. Leading etiologies of massive hemoptysis include bronchiectasis, tuberculosis, and bronchogenic carcinoma. Massive hemoptysis places the patient at high risk for asphyxiation and death and since Emergency Physicians encounter such cases infrequently, familiarity with current management options ahead of time is important.

Options for bleeding control can include balloon tamponade via bronchoscopy, bronchial artery embolization (BAE, interventional radiology), and emergent surgical resection. BAE is now the most successful non-surgical treatment of massive hemoptysis, successfully stopping bleeding in > 85% of cases. This angiographic technique involves cannulation of the bronchial artery that supplies the area of hemorrhage and embolization with polyvinyl alcohol particles or absorbable gelatin powder (Gelfoam). While surgery remains the only truly definitive therapy, it is best avoided in the acute emergent setting if possible.References: (1) Swanson, KL, et al. Bronchial artery embolization: experience with 54 patients Chest 2002; 121:789. (2) Remy-Jardin, M, et al. Bronchial and Nonbronchial Systemic Arteries at Multi-Detector Row CT Angiography: Comparison with Conventional Angiography Radiology 2004; 233:741. (3) Ashleigh RJ, Webb AK. Radiological intervention for haemoptysis in cystic fibrosis J R Soc Med 2007;100 Suppl 47:38-45. (4) Wong, ML, et al. Percutaneous embolotherapy for life-threatening hemoptysis Chest 2002; 121:95.

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