Massive hemoptysis / Nahid Sherbini

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  • 1.HEMOPTYSIS Dr Nahid Sherbini Consultant IM & Pulmonary KFH ,Medina ,SA

2. Definition of Hemoptysis The spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. Stedman TL. Stedmans Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000 3. Severity Classification GRADE AMOUNT /24 HRS Mild < 50 ml Moderate 50 - 200 ml Severe**/Major* > 200 ml * 150 ml per 12 hrs or** >400 ml per 24 hrs Massive > 600 ml Life-threatening 200 ml/h or 50 ml/h with respiratory failure. *Corey R, Hla KM.Am J Med Sci 1987; 294:301309. **de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790795 #Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829833. 4. Massive hemoptysis Up to 1000 mL (1) Either 500 mL of expectorated blood over a 24 h or bleeding at a rate 100 mL/h, regardless of whether abnormal gas exchange or hemodynamic instability exists. (2) (1)Major and massive hemoptysis: reassessment of conservative management.- Corey R, Hla Am J Med Sci. 1987;294(5):301. (2)Uptodate.inc 5. Bronchial arteries (90%) Pulmonary arteries Source of bleeding *Remy J, Remy-Jardin M, Voisin C: Endovascular management of bronchial bleeding; in Butler J (ed): The Bronchial Circulation. New York, Dekker, 1992, pp 667723. 6. Bronchial arteries Systemic pressure Bronchi, vagus nerve, posterior mediastinum, and esophagus. 6 2 Left bron.art 1 Rt.bron.art T5 -T6 7. Figure 1. Diagrams illustrate the types of bronchial arterial supply: Type I, two bronchial arteries on the left and one on the right that manifests as an ICBT (40.6% of cases); Type II, one on the left and one ICBT on the right (21.3%); Type III, two on t... Yoon W et al. Radiographics 2002;22:1395-1409 2002 by Radiological Society of North America 8. Pulmonary arterial system RV Low pressure system 8-25mmHg . 9. Causes 10. Infectious Tuberculosis Fungal infections Necrotizing pneumonia and lung abscess Bacterial endocarditis with septic emboli Parasitic (paragonimiasis, hydatid cyst) It is the most common cause of hemoptysis worldwide with 2 billion people infected worldwide with 5-10% developing disease (Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 89.) 11. Neoplastic Bronchogenic carcinoma Endobronchial tumors e.g carcinoid Metastasis Bronchiectasis CF Bullous emphysema Alveolar hemorrhage and underlying causes Pulmonary 12. Vascular Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic, arteritis) Bronchial artery aneurysm PE Pulm HTN Airway-vascular fistula AV Malformations MS LVF 13. Vasculitis Wegeners granulomatosis Goodpastures syndrome Behets disease SLE Coagulopathy /Platelet disorders Uremia/ Platelet dysfunction Anticoagulant therapy Haematological 14. RISK FACTORS FOR MORTALITY 1. Infiltrates involving 2 or more quadrants on an admission CXR 2. Bleeding from the pulmonary artery 3. Cancer 4. Aspergillosis 5. Alcoholism 6. Mechanical Ventilation & Aspiration in to contralateral lung * Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis.Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF, Stoclin A, Mayaud C, Cadranel J, Ancel PY -Respiration. 2012;83(2):106. 15. Predictors of Mortality 71% in patients who lost =>600 ml of blood in 4 h 22% in patients with =>600 ml within 416 h 5% in those with 600 ml of within 1648 h Life-threatening massive : 5 to 15%. *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med 1968;121: 495498. 16. MANAGEMENT 17. Air way Breathing Circulation Provide suction. Provide O2 crystalloid solutions AND blood products 18. INITIAL STEPS 1. IDENTIFY WHICH SIDE IS BLEEDING 2. POSITION THE PATIENT 3. ESTABLISH A PATENT AIRWAY 4. INSURE ADEQUATE GAS EXCHANGE 5. INSURE ADEQUATE CVS FUNCTION 6. CONTROL THE BLEEDING 19. DIAGNOSTIC MODALITIES 20. History Does the patient have known pulmonary, cardiac, or renal disease?- smoke? Prior hemoptysis, other pulmonary symptoms, or infectious symptoms? FH of hemoptysis, brain aneurysms, epistaxis, or GI ? a skin rash? Exposed to asbestos? Bleeding disorder? DVT risk? DRUGS? Has the patient had (TB) or been exposed to TB? 21. Physical Examination Telangiectasias A skin rash,Splinter hemorrhages ,Needle tracks IE An audible chest bruit or murmur that increases with inspiration a large pulmonary AV malformation. P2, TR or PR, or RV lift Heart murmurs MS , CHD DVT signs 22. Laboratory tests Type and cross-matching CBC ,COAG Electrolytes, BUN ABG Liver function tests Urinalysis Special tests 23. CXR Site of bleeding in 3382% *of cases. Underlying cause in 35%**. Rarely normal *Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF: Utility of high-resolution chest CT scan in the emergency management of hemoptysis in the intensive care unit: severity, localization and aetiology. BJR 2007; 80: 2125. **Hirshberg B, Biran I, Glazer M, Kramer MR:Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112: 440444. 24. Bronchoscopy Flexible bronchoscopy is the initial diagnostic procedure of choice : performed at the bedside, it is readily available, and it is highly successful at localizing the bleeding site if it is performed while the patient is bleeding. Intubation should be considered . Massive hemoptysis. Assessment and management. Cahill BC, Ingbar DH Clin Chest Med. 1994;15(1):147. 25. CT SCAN Superior to CXR Correct localization in 7088.5% of cases* Multidetector CT - bronchial and nonbronchial systemic arteries . Better than bronchoscopy for determining the cause of bleeding. *Haponik EF, Britt EJ, Smith PL, Bleecker ER:Computed chest tomography in the evaluation of hemoptysis: impact on diagnosis and treatment. Chest 1987; 91: 8085. 26. Figure 9. Bronchial artery. Yoon W et al. Radiographics 2002;22:1395-1409 2002 by Radiological Society of North America 27. Figure 8. Bronchial artery. Yoon W et al. Radiographics 2002;22:1395-1409 2002 by Radiological Society of North America 28. Arteriography Persistent bleeding following bronchoscopy. The preceding bronchoscopy may be helpful in identifying the area of bleeding assisting the radiologist in locating the precise bleeding site. Therapeutic embolization is possible during the diagnostic arteriography procedure. 29. Figure 10c. Value of preliminary thoracic aortography. Yoon W et al. Radiographics 2002;22:1395-1409 2002 by Radiological Society of North America 30. Clues to bronchial artery as the source of bleeding: Parenchymal hypervascularity Vascular hypertrophy aneurysm 31. The identification of extravasated dye --INFREQUENT Bronchopulmonary shunting Neovasculirization 32. BRONCHOSCOPIC AND AIRWAY MANAGEMENT 33. IDENTIFY WHICH SIDE IS BLEEDING POSITION THE PATIENT ESTABLISH A PATENT AIRWAY INSURE ADEQUATE GAS EXCHANGE INSURE ADEQUATE CVS FUNCTION CONTROL THE BLEEDING 34. Protection of nonbleeding lung If bleeding side is known Keep patient at: -Rest -Lateral decubitus -Bleeding side down Rt.Main bronchus Left main brochus flooded with blood 35. IDENTIFY WHICH SIDE IS BLEEDING POSITION THE PATIENT ESTABLISH A PATENT AIRWAY INSURE ADEQUATE GAS EXCHANGE INSURE ADEQUATE CVS FUNCTION CONTROL THE BLEEDING 36. CONTROL THE BLEEDING Non-surgical Blood products Bronchoscopic measures BAE Surgery 37. Bronchoscopic Measures Endobronchial >Unilateral lung vent >Double-lumen ETT >Balloon tamponade Bronchial irrigation Vasoconstrictive agents Lasers Thermal Therapy 38. Selective Intubation SINGLE LUMEN ETT Selectively intubate the non bleeding lung. Selective intubation of L Main bronchus in R sided massive hemoptysis 39. Selective Intubation DOUBLE LUMEN ETT Specially designed for selective intubation of the right or left main bronchi Last option in an asphyxiating pt. 40. FOB - diagnostic Identifies the site of bleeding in 7393%* Early versus delayed. (brownish or black gelatinous mass -->clot. Successful in life threatening hemoptysis. Immediate arrest of bleed: 98%(56 of 57) *Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade therapy for the Management of life-threatening hemoptysis. Chest 2005; 127: 21132118. 54. Bronchoscopy-Guided Topical Hemostatic Tamponade(THT) 56 55. Bronchoscopy-Guided Topical Hemostatic Tamponade(THT) Endobronchial view of a bleeding subsegmental bronchus before THT During bronchoscopy guided THT 56. Bronchoscopy-Guided Topical Hemostatic Tamponade(THT) Disavantages: Not suitable for proximal sites, trachea. Patients who cannot tolerate occlusion. Recurrence of hemoptysis 57. Endobronchial Sealing with Biocompatible Glue Material: n-butyl cyanoacrylate(adhesive) Injected into the bleeding airway through a catheter via a flexible FOB. Used in mild hemoptysis. * *Parthasarathi Bhattacharyya et al Bronchoscopy Centre, Calcutta, India(CHEST 2002; 121:20662069) 58. Endobronchial Sealing with Biocompatible Glue 60 59. Laser Photocoagulation Nd-YAG laser Effective in: Bronchoscopically visible source. MECHANISM: Photocoagulation of the bleeding mucosa with resulting hemostasis. Achieves photoresection and vaporization *Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection. Chest 1982; 81: 278284. 60. Argon Plasma Coagulation(APC) TYPE : Thermal tissue destruction Non contact electrocoagulation tool*. Used: In bronchoscopically visible areas of sources of bleed 62 *Keller CA, Hinerman R, Singh A, Alvarez F: The use of endoscopic argon plasma coagulation In airway complications after solid organ transplantation. Chest 2001; 119: 19681975. APC machine 61. 63 Flooding of the bron.intermed. Suctioning airway clearance visualizati