Massive Hemoptysis

  • View
    51

  • Download
    0

Embed Size (px)

DESCRIPTION

Massive Hemoptysis. D. P. Laporta MD Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital McGill University presented to McGill Residents Critical Care (January 2000) Pulmonary (July July 2000. MASSIVE HEMOPTYSIS REFERENCES. - PowerPoint PPT Presentation

Text of Massive Hemoptysis

  • D. P. Laporta MD

    Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General HospitalMcGill University

    presented to McGill ResidentsCritical Care (January 2000)Pulmonary (July July 2000

  • MASSIVE HEMOPTYSIS

    REFERENCESBone: Pulmonary & Critical Care Medicine, 1998 ed., 1998 Mosby-Year Book, Inc. Ch R19 Massive HemoptysisCh M10 Pulmonary Hemorrhage Syndromes

    Jean Baptiste E clinical Assessment and management of massive hemoptysis Crit Care Med 2000; 28:1642-7

    Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis, in: Flexible bronchoscopy in the 21st century. Clin. Chest Med. 1999; 20(1) March White R. Jr. Bronchial Artery Embolotherapy for Control of Acute Hemoptysis. Analysis of Outcome . Chest 1999; 115(4) April

    Fanburg BL et al, Case 52-1993: A 17-Year-Old Girl with Massive Hemoptysis and Acute Oliguric Renal Failure. NEJM Weekly CPC. 1993; 329(27)

  • MASSIVE HEMOPTYSIS

    Definition

    Natural History

    Investigations

    CXR

    FOB

    CT

    Others: echo, V/Q, Duplex, Pulm Angio, Bloodwork

    Interventions

    Medical: conservative, BAE

    Surgical

  • HEMOPTYSIS

    USUAL HEMOPTYSIS

    Frequent

    Life Frightening

    1% to 14% of all patients with hemoptysis

    MASSIVE HEMOPTYSIS

    Rare ( 1-14 % of pts with H)

    Life Threatening

    one of the most frightening of medical emergencies

    for patient and physician !!!

    CHALLENGE:

    explosive clinical presentation

    MAJOR RISK: impending asphyxiation

    need to respond quickly and appropriately

  • MASSIVE HEMOPTYSIS

    NATURAL HISTORY AND PROGNOSIS

    MORTALITYImmediate: 7% of 113 patients who presented with massive hemoptysis died soon after onset. Etiology: TB 18.6%, CF 32%, Other 10%DURATIONIf survive the initial episode, bleeding stops

  • MASSIVE HEMOPTYSIS

    Prognostic Features Associated with Death

    bleeding exceeding 1000 mL/24 h600 mL of hemoptysis in 1L/24 h PLUS malignancy

  • Overestimate

    Underestimate400 ml = abN gas XC

    MASSIVE HEMOPTYSIS

    DEFINITIONS

    > INCLUREIMAGE \d "/images/isochar/ge.gif"100 mL/24 hrs

    > 200 mL/24 hrs

    > 300 mL/24 hrs

    ( 600 mL/24 hrs

    > 1000 mL/24 hrs

    INCLUREIMAGE \d "/images/isochar/ge.gif"

  • Hemoptysis: is it real ?GIFactitious (Munchausens)Pseudo:drugs (RFP, clofazimine)Serratia pneumoniaENT

  • MASSIVE HEMOPTYSIS

    SOURCES OF HEMOPTYSIS

    2 interconnected circulations:

    pulmonary (low pressure)

    bronchial (systemic pressure)

    proximal airways (trachea and main stem bronchi) RA

    peripheral airways/parenchyma bronchopulmonary

    anastomoses (r-l shunt) pulmonary veinsLA

  • Bronchial CirculationCome directly or indirectly from the aorta (T3-8)Variability

  • Nonbronchial systemic collateral arteries in 45% of patients with hemoptysis

    commonly: intercostal, subclavian, axillary & phrenics

    uncommonly: IMA, thyrocervical, carotid, coronaries

    Because of the many systemic arteries involved, routine arteriographic localization cannot be all-inclusive

  • MASSIVE HEMOPTYSIS ETIOLOGY (1)

    Infectious (bacterial, mycobacterial, viral, fungal, parasitic) Lung abscessBronchiectasis (including cystic fibrosis)Mycetoma (e.g., aspergilloma)Infected BP SequestrationSeptic emboli Infected aortic graftNeoplasm MalignantBronchogenicMetastasis from pulmonary/extrapulmonaryBenign (bronchial adenoma)

  • MASSIVE HEMOPTYSIS ETIOLOGY (2)

    Foreign body/trauma Aspirated foreign body Broncholith Tracheovascular fistula Trauma, Brachytherapy, LaserCardiac/pulmonary vascular Pulmonary venous HTNMitral stenosis, PVOD(Pulmonary embolus) Pulmonary artery Perforation (complicating Swan-Ganz catheter) Aneurysm/false (mycotic, Behcets, Hughes-Stovin)Arteriovenous malformationsOWR, DieuLaFoyeFistulae (every vessel parring through the thorax)

  • MASSIVE HEMOPTYSIS ETIOLOGY (3)

    Alveolar hemorrhage Goodpasture's syndromeSystemic vasculitides/collagen vascular diseasescapillaritis Behcet's syndrome Essential mixed cryoglobulinemia, Henoch-Schonlein purpura Progressive systemic sclerosis Rheumatoid arthritis, Systemic lupus erythematosus, Mixed connective tissue disease Systemic necrotizing vasculitis, Wegener's granulomatosis Other GlomerulonephritisImmune complex associated glomerulonephritis Pauci-immune glomerulonephritisFamilialAcute Leukemias

  • MASSIVE HEMOPTYSIS ETIOLOGY (4)

    Drug-inducedCocaine, D-penicillamine, Isocyanates, Nitrofurantoin, Trimellitic anhydrideAnticoags, Thrombolytics, ASA

  • MASSIVE HEMOPTYSIS ETIOLOGY (4)

    MiscellaneousIdiopathic hemosiderosis Coagulation disordersThrombotic thrombocytopenic purpura DICAcquired coagulopathy (permissive)Endometriosis (Catamenial hemoptysis)Sarcoidosis LymphangioleiomyomatosisChronic Lung DiseaseEmphysematous bullaePneumoconiosis

  • MASSIVE HEMOPTYSIS BEDSIDE ASSESSMENT OF THE PATIENT Clubbing, Simian crease, Cutaneous nodules/pustules + uveitis IVDU with septic thrombophlebitis, palpable purpura, malar rash Oral: ulcers, mucosal telangiectasias, Post-URI rhinitis, saddle nose Stridor/wheezing

  • MASSIVE HEMOPTYSIS Clinical HistoryYoung adult female ... otherwise healthy with recurrent CHF & A fib with spontaneous pneumothorax + ILD menstruating

  • MASSIVE HEMOPTYSIS Clinical HistoryInflammatory Lung Diseases bronchiectasis abscess necrotizing pneumonia infected cavity/bulla (mycetoma)

  • MASSIVE HEMOPTYSIS Clinical History

    TUBERCULOSISmore common in the presence of cavitary disease.

    pathologic lesionsRasmussen's aneurysmsbronchial artery erosions from tb airway inflammation or bronchiectasis;secondary infections of prior tuberculous cavities (eg Aspergillus)

  • Specific clinical situations presenting with MASSIVE HEMOPTYSISTracheostomyPost-Partum Southeast Asia, Middle East South AmericaLymphomaAcute LeukemiaCardiac Surgery

  • High-power magnification showing capillaritis, which is characterized by infiltration of the alveolar septae by neutrophils (arrow). Note the presence of scattered red cells in the parenchyma (H&E stain, original magnification 400).

  • DIFFUSE ALVEOLAR HEMORRHAGEBloody BAL fluidhemosiderin-laden macrophageslack of infectious pathogens

    ...are sufficient to establish DAH.

  • Causes of MH Associated With a Normal Chest Radiograph

    PRIVATE

    Bronchiectasis

    Pulmonary embolism

    Lung carcinoma in the trachea or large airways

    Pulmonary artery dissection or rupture

  • MANAGEMENT of MH1. Make the right etiological DIAGNOSIS !Hx. Px, Sputum, Bloods, FOB, Imaging

    2. Determine the SITE of bleeding Hx, Px, CXR (?CT)FOB : flexible, rigidobserve mucosa etc., washings: culture incl TB, cytology

    3. Airway control/pt stabilizationsurgical candidate ?4. Specific Therapy

  • PRIVATE STEP

    SPECIFIC RECOMMENDATIONS/OPTIONS

    COMMENTS/RATIONALE

    (1) PROTECT AIRWAY AND STABILIZE PATIENT

    Admit and monitor

    Intensive care unit

    Allows close monitoring of hemodynamics and magnitude of blood loss

    Maintain adequate airway

    INCLUREIMAGE \d "/images/isochar/ge.gif"Size 8 endotracheal tube

    To facilitate suctioning/bronchoscopy

    Consider double lumen tube

    Consider unilateral intubation

    Bronchoscopy can help verify placement

    Supplemental oxygen

    Correct coagulopathy

    Blood, fresh frozen plasma

    Fluid resuscitation

    Consider intravenous vasopressin

    Stool softeners

    Prevent straining

    Cough suppressants

    Lateralize bleeding

    Bleeding lung down

  • If bleeding lateralized rather than localized:

    A right-sided bleeding :

    B left-sided bleeding

    L lung selectively intubated

    trachea intubated over bronchoscope first

    Over the bronchoscope. with the patient in the left lateral position to minimize aspiration

    14Fr 100 cm Fogarty catheter passed through the vocal cords beside the endotracheal tube to a level several centimeters below the cuff.

  • DOUBLE LUMEN ETT FOR ENDOBRONCHIAL TAMPONADE.

    bronchial lumen: placed in L main bronchus to ventilate L lung

    tracheal lumen: remains supracarinal to ventilate R lung

    and prevents occlusion of the RUL orifice.

    external lumina connected to ventilator using a "Y" connector device.

    Left and right-sided double lumen tubes are currently available.

  • DOUBLE-LUMEN ETT IN MASSIVE HEMOPTYSISRequires expertSmall lumina: difficult insertion, easy obstruction62 patients with MH4/7 pts with DL-ETT: aspiration and deathcause: loss of tube position and pulmonary aspiration during surgery.L bronchial ETI:0/12 deaths fromL Fogarty- Tracheal ETI: aspiration

  • (2) LOCALIZE THE SOURCE OF BLEEDING

    Hx, Px

    Radiology

    CXR

    Bronchoscopy

    Flexible

    Rigid

    Early bronchoscopy helps identify exact location and guide further management

    LIMITATIONS:

    Upper lobes

    Peripheral disease

  • TIMINGOF BRONCHOSCOPY

    The sicker, the earlier !

    site of bleeding visualized more commonly with early bronchoscopy (within 48 hours)

    unlikely relevant in non-massive hemoptysis

  • (3) ADMINISTER SPECIFIC

    THERAPY

    Bronchoscopic therapies

    Iced saline lavage

    Topical agents

    Epinephrine, thrombin, thrombin-fibrinogen

    Endobronchial tamponade

    Size 4 to 7 French catheter, J-wire (through nostril), bronchus blocker

    Laser photocoagulation