Massive Hemoptysis

Morning Report Hili Morillas, MD January 6, 2006

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.