Massive Hemoptysis

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 Rasmussen’s). 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, Kartagener’s) 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.