Massive hemoptysis

Yonas A.
June, 2016

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 Massive hemoptysis
• It is generally defined as expectoration of over 600 mL
of blood within a 24-hour period
• It is a medical emergency associated with a mortality
rate of 30 to 50%
• Use of an absolute volume criterion presents difficulties
– First, it is difficult for the patient or caregivers to quantify the
volume of blood being lost
– Second, and most relevant, the rate of bleeding necessary to
incite respiratory compromise is highly dependent on the
individual's prior respiratory status

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 Anatomy
• The lungs have two sources of blood supply:
– The pulmonary arteris: A high-compliance, low-pressure system,
and the walls of the pulmonary arteries are very thin and delicate
– The bronchial arteries: Have systemic pressures and thick walls;
most branches originate from the proximal thoracic aorta

• Most cases of massive hemoptysis involve bleeding from the

bronchial artery circulation or from the pulmonary circulation
pathologically exposed to the high pressures of the bronchial
circulation
– The systemic pressures within these (bronchial) arteries, combined
with a disease process within the airway and erosion, lead to
bleeding
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 Causes
• Most are secondary to inflammatory processes
• Common causes
– Acute necrotizing pneumonia
– Chronic inflammatory disorders (i.e., tuberculosis
bronchiectasis, cystic fibrosis, and others)
– Lung cancer
• Usually mild, resulting in blood-streaked sputum
• Massive hemoptysis in patients with lung cancer is typically
caused by malignant invasion of pulmonary artery vessels by
large central tumors; although rare, it is often a terminal event

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 Cont.
• Tuberculosis also can cause hemoptysis by:
– Erosion of a broncholith (a calcified tuberculous
lymph node) into a vessel
– Erosion of a blood vessel within a TB cavity
• Within such cavities, aneurysms of the pulmonary
artery (referred to as Rasmussen's aneurysm) can
develop that are accompanied by subsequent erosion
and massive bleeding
– Erosion of a damaged airway in to a bronchial
artery
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 Management
• Best managed by a multidisciplinary team of
intensive care physicians, interventional radiologists,
and thoracic surgeons
• Principles of management
– (1) achieve respiratory stabilization and prevent
asphyxiation
– (2) localize the bleeding site
– (3) stop the hemorrhage
– (4) determine the cause
– (5) definitively prevent recurrence

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 Scenario 1
• Significant, Persistent, But Nonmassive Bleeding (patient may
be able to maintain clearance of the blood and secretions with
his or her own respiratory reflexes)
– Admission to an ICU
– Administration of humidified oxygen and monitoring of oxygen
saturation and arterial blood gases
– Insertion of large-bore intravenous catheters
– Strict bedrest
• Strict bedrest with sedation may lead to slowing or cessation of bleeding
• Trendelenburg positioning with the affected side down (if known)
– Administration of aerosolized adrenaline
– IV vasopressin
– Intravenous antibiotic therapy if needed
– Correction of abnormal blood coagulation study 7
 Cont.
• Evaluation
– CXR Pathologic areas may be obscured by blood soiling
– CT scan
– Flexible bronchoscopy
• It allows diagnosis of airway abnormalities and will usually permit localization of
the bleeding site to either a lobe or even a segment
• Apply excellent suction and perform saline lavage with a dilute solution of
epinephrine
– Bronchial arteriography and embolization
• Embolization will acutely arrest the bleeding in 80 to 90% of patients
– However, 30 to 60% of patients will have recurrences
» Subsequently, definitive treatment of the underlying pathologic process is appropriate
• If bleeding persists after embolization, a pulmonary artery source should be
suspected and a pulmonary angiogram performed
– Surgery If respiratory compromise is impending, orotracheal
intubation should be performed 8
 Scenario 2

• Significant, Persistent, and Massive Bleeding

– Life-threatening bleeding requires emergency
airway control and preparation for potential surgery
• Immediate orotracheal intubation
– To gain control of ventilation and suctioning
• Immediate transport to the OR with rigid bronchoscopy
• Rigid bronchoscopy
– Intubate the nonbleeding side and ventilate the patient
– Suction the bleeding with visualization of the bleeding site
– After stabilization, perform ice-saline lavage of the bleeding site
– Bleeding stops in up to 90% of patients
• Surgery 9
 Surgical Intervention
• In most patients, bleeding can be stopped, recovery can occur,
and plans to definitively treat the underlying cause can be
made
• In less than 10% of patients, emergency surgery will be
necessary, delayed only by efforts to localize the bleeding site
by rigid bronchoscopy
• General indications for urgent surgery
– Failure to control the bleeding The walls of the cavities are eroded
and necrotic; rebleeding will likely
– Fungus ball
ensue
– Significant cavitary disease
– Lung abscess Bleeding may be due to pulmonary
artery erosion, which requires
surgery for control 10
The end!

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