Massive Hemoptysis, 1-6-06

7/29/2019 Massive Hemoptysis, 1-6-06

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Massive Hemoptysis

Morning ReportHili Morillas, MD

January 6, 2006


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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%.


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Massive Hemoptysis

Must r/o non-pulmonary causesupper

airway or gastrointestinal tract

Alkaline pH, foaminess, or the presence of

pus may sometimes suggest the lungs as theprimary source of bleeding


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

ACLS first and control of their bleeding.

Secondary goals are determining the site andcause of the bleeding and whether or not thepatient is a surgical candidate.


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History

Prior lung, cardiac, or renal disease?

History of cigarette smoking?

Prior hemoptysis, other pulmonary

symptoms, or infectious symptoms?

Family history of hemoptysis or brainaneurysms (suggesting hereditary

hemorrhagic telangiectasia)?


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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?


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Physical Exam

Telangiectasias -- hereditary hemorrhagictelangiectasia.

Skin rash -- vasculitis, systemic lupuserythematosus, fat embolism, or infectiveendocarditis.

Splinter hemorrhages -- endocarditis orvasculitis.

Clubbing is nonspecific, since it can occur in

many chronic lung diseases.


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Physical Exam

Audible chest bruit or murmur that increaseswith inspiration -- large pulmonary AVmalformations .

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

stenosis. Legs should be examined carefully for

possible deep venous thrombi.


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Causes of hemoptysis

90 % of cases are due to:

TB

Bronchiectasis

Lung abscesses


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Tuberculosis

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

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


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Tuberculosis

Sudden rupture of a Rasmussen's aneurysm

Inactive TB can cause bleeding due to residualbronchiectasis, erosion of a broncholith through avessel and into an airway, or by a cavity thatsubsequently acquires a mycetoma.

The source of bleeding in each of these causes isusually the bronchial arterial circulation (exceptRasmussens).


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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.


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Bronchiectasis

Results from prior infection (bacterial or

viral), cystic fibrosis, TB, or impairment of

the mucociliary clearance apparatus (PCD,

Kartageners)


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Infections

Bleeding may occur acutely from necrosis of lungtissue 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 massivealveolar bleeding and hemoptysis


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Lung Cancer

Bronchogenic carcinoma usually causes

nonmassive hemoptysis.

Hemoptysis occurs at presentation in 7 to

10% of patients.

Hemoptysis occurs during the disease coursein approximately 20%.


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Immunologic Lung Disease

Goodpasture's syndrome

Wegener's granulomatosis

Systemic lupus erythematosus (SLE)

Idiopathic pulmonary hemosiderosis.

Pathologically, many of these diseases havecomponents of pulmonary capillaritis


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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 optimalmanagement of these patients.


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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


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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!!!


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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 duringa left lung bleed. Risk = blocking RUL bronchus

Balloon tamponade via bronchoscopy

Placement of a double lumen ETT speciallydesigned for selective intubation of the right or leftmainstem bronchi Used as a last option in an asphyxiating pt.


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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.


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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 following6-12 months.


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Management with Surgery

Patients with lateralized, uncontrollable bleedingshould be assessed early.

Usual assessment includes pulmonary functiontests, but often these patients are too ill for

physiologic testing

Relative contraindications to surgery are: severe

underlying pulmonary disease, active TB, cysticfibrosis, multiple AVMs, multifocal bronchiectasis,and diffuse alveolar hemorrhage.


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Morbidity

Comparison of medical and surgical treatment formassive 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 whoqualified as surgical candidates.

However, medically treated patients probably havea higher risk of rebleeding within the first six

months

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Massive Hemoptysis, 1-6-06