{"id":5095,"date":"2011-07-14T20:23:22","date_gmt":"2011-07-14T20:23:22","guid":{"rendered":"http:\/\/crashtext.org\/misc\/massive-hemoptysis.htm\/"},"modified":"2013-10-06T23:58:14","modified_gmt":"2013-10-07T03:58:14","slug":"massive-hemoptysis","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/","title":{"rendered":"Massive Hemoptysis"},"content":{"rendered":"

Best Review of Massive Hemoptysis Dx and Rx <\/a><\/p>\n

<\/span>Causes<\/span><\/h2>\n

bleeding from the bronchial rather than the pulmonary circulation causes ~88% of hemoptysis.<\/p>\n

<\/span>Bronchitis<\/span><\/h3>\n

rarely the cause for massive, but most common cause of submassive hemoptysis<\/p>\n

dilated bronchial arteries erode during inflammation of airways<\/p>\n

always consider lung ca in patients with bronchitis from smoking<\/p>\n

<\/span>Lung Cancer<\/span><\/h3>\n

most common with squamous<\/p>\n

<\/span>Bronchiectasis<\/span><\/h3>\n

abnormal dilation of the bronchi with altered mucociliary clearance, persistent bacterial colonization, chronic inflammation, and submucosal neovascularization. Cover with broad spectrum antibiotics.\u00a0 Cystic Fibrosis has similar pathology and can result in massive bleeding.\u00a0 In this case directed therapy against pseudomonas should be initiated use antipseudomonal penicillin with aminoglycoside.<\/p>\n

<\/span>Tuberculosis<\/a><\/span><\/h3>\n

complicates ~25% cases.\u00a0 Often caused by a Rasmussen’s aneurysm, a small outpouching of the pulmonary vasculature within a cavity wall.\u00a0 TB can also result in bronchiectasis and antibiotics are needed if this is the cause of the hemoptysis.<\/p>\n

<\/span>Lung Abscess<\/span><\/h3>\n

anaerobic abscesses in areas of aspiration<\/p>\n

<\/span>Other Pulmonary Infections<\/span><\/h3>\n

massive hemoptysis is only seen with tissue necrosis such as with anaerobic, staphylococcal, and actinomycotic infections.\u00a0 Septic pulmonary embolisms can also trigger bleeding.\u00a0 Invasive aspergillus can be found in COPD patients as well as neutropenic patients.\u00a0 Pulmonary mucormycosis and the other fungal pathogens are also occasionally responsible.<\/p>\n

<\/span>Pulmonary Embolism<\/span><\/h3>\n

as mentioned especially in septic emboli, but any clot can cause bleeding<\/p>\n

 <\/p>\n

Less Common:<\/p>\n

<\/span>Aspergillus Fungus Balls<\/span><\/h3>\n

can complicate TB and sarcoidosis<\/p>\n

<\/span>Catamenial Hemoptysis<\/span><\/h3>\n

with the onset of menses, from aberrant endometrial tissue<\/p>\n

 <\/p>\n

<\/span>Rasmussen’s aneurysm<\/span><\/h3>\n

common in TB pts<\/p>\n

pulmonary vessel ruptures into cavitary lesion<\/p>\n

<\/span>Diffuse Alveolar Hemorrhage<\/span><\/h3>\n

multiple causes, but if also renal problems, significantly narrowed differential<\/p>\n

may need high dose steroids (Solumedrol 1-2 grams)<\/p>\n

 <\/p>\n

Immunologic Lung Disease<\/h4>\n

Goodpasture’s<\/b><\/p>\n

Antibasement Membrane Disease<\/p>\n

pulmonary hemorrhage and renal disease<\/p>\n

after stabilization, need steroids and immunosuppresion<\/p>\n

SLE<\/b><\/p>\n

Wegener’s Granulomatosis<\/b><\/p>\n

c-ANCA is 97% specific and 85% sensitive<\/p>\n

Idiopathic Pulmonary Hemosiderosis<\/b><\/p>\n

Immunocompromise<\/b><\/p>\n

complicates autologous bone marrow transplantation<\/p>\n

post transplant<\/p>\n

Bleeding Diathesis<\/b><\/p>\n

Drug Induced<\/b><\/p>\n

from crack cocaine<\/p>\n

 <\/p>\n

\"\"<\/p>\n

<\/span>Vascular Abnormalities<\/span><\/h3>\n

Aortobronchial<\/h4>\n

Pulmonary Artery Aneurysms<\/h4>\n

Arteriovenous Malformations<\/h4>\n

<\/span>Trauma<\/span><\/h3>\n

<\/span>Iatrogenic<\/span><\/h3>\n

catheters and bronchoscopes<\/p>\n

<\/span>Diagnosis<\/span><\/h2>\n

localization is first priority<\/p>\n

Get C-XR<\/p>\n

May need radionuclide studies or chest ct<\/p>\n

Bronchoscopy is the best single test to localize the source of bleeding<\/p>\n

<\/span>Management<\/span><\/h2>\n

150-200 cc can fill a large portion of the bronchial tree<\/p>\n

 <\/p>\n

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

Use the largest possible ET tube<\/p>\n

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.<\/p>\n

Double lumen tubes may be used if available<\/p>\n

Endobronchial tamponade with balloon catheters<\/p>\n

place the patient with the bleeding lung dependant<\/p>\n

 <\/p>\n

If bleeding stops spontaneously, the patient may be managed expectantly.\u00a0 Give cough suppression with codeine<\/p>\n

Laser photocoagulation can be used as well as endobronchial infusion fibrinogen-thrombin.<\/p>\n

 <\/p>\n

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.<\/p>\n

The final step is surgical resection<\/p>\n

 <\/p>\n

 <\/p>\n

Management of Massive Hemoptysis<\/strong> Massive hemoptysis is variably defined as expectoration of blood > 100 – 600 mL over 24 hours.\u00a0 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.<\/p>\n

Options for bleeding control can include balloon tamponade via bronchoscopy, bronchial artery embolization (BAE, interventional radiology), and emergent surgical resection. \u00a0BAE 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:<\/em> (1) Swanson, KL, et al. Bronchial artery embolization: experience with 54 patients Chest<\/em> 2002; 121:789. (2) Remy-Jardin, M, et al. Bronchial and Nonbronchial Systemic Arteries at Multi-Detector Row CT Angiography: Comparison with Conventional Angiography \u00a0Radiology<\/em> 2004; 233:741. (3) Ashleigh RJ, Webb AK. Radiological intervention for haemoptysis in cystic fibrosis J R Soc Med <\/em>\u00a02007;100 Suppl 47:38-45. (4) Wong, ML, et al. Percutaneous embolotherapy for life-threatening hemoptysis \u00a0Chest<\/em> 2002; 121:95.<\/p>\n

‘<\/p>\n

(EMEDHOME)<\/p>\n

 <\/p>\n

|\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"

Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[32],"tags":[],"yoast_head":"\nMassive Hemoptysis - Crashing Patient<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"CrashMaster\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/\",\"url\":\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/\",\"name\":\"Massive Hemoptysis - Crashing Patient\",\"isPartOf\":{\"@id\":\"https:\/\/crashingpatient.com\/#website\"},\"datePublished\":\"2011-07-14T20:23:22+00:00\",\"dateModified\":\"2013-10-07T03:58:14+00:00\",\"author\":{\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d\"},\"breadcrumb\":{\"@id\":\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/crashingpatient.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Massive Hemoptysis\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/crashingpatient.com\/#website\",\"url\":\"https:\/\/crashingpatient.com\/\",\"name\":\"Crashing Patient\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/crashingpatient.com\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d\",\"name\":\"CrashMaster\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/image\/\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g\",\"caption\":\"CrashMaster\"},\"url\":\"https:\/\/crashingpatient.com\/author\/emcrit\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Massive Hemoptysis - Crashing Patient","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/","twitter_misc":{"Written by":"CrashMaster","Est. reading time":"4 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/","url":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/","name":"Massive Hemoptysis - Crashing Patient","isPartOf":{"@id":"https:\/\/crashingpatient.com\/#website"},"datePublished":"2011-07-14T20:23:22+00:00","dateModified":"2013-10-07T03:58:14+00:00","author":{"@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d"},"breadcrumb":{"@id":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/crashingpatient.com\/medical-surgical\/pulmonology\/massive-hemoptysis.htm\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/crashingpatient.com\/"},{"@type":"ListItem","position":2,"name":"Massive Hemoptysis"}]},{"@type":"WebSite","@id":"https:\/\/crashingpatient.com\/#website","url":"https:\/\/crashingpatient.com\/","name":"Crashing Patient","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/crashingpatient.com\/?s={search_term_string}"},"query-input":"required name=search_term_string"}],"inLanguage":"en-US"},{"@type":"Person","@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d","name":"CrashMaster","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/image\/","url":"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g","caption":"CrashMaster"},"url":"https:\/\/crashingpatient.com\/author\/emcrit\/"}]}},"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts\/5095"}],"collection":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/comments?post=5095"}],"version-history":[{"count":0,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts\/5095\/revisions"}],"wp:attachment":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/media?parent=5095"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/categories?post=5095"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/tags?post=5095"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}