Makindo Medical Notes.com

Related Subjects: |Lung Cancer

In the case of Massive Haemoptysis protect the good lung at the expense of the bad lung. Death is from asphyxiation and hypoxia, not exsanguination if it is a unilateral process

About

• As little as 250 mL can fill the bronchial tree. This is life-threatening but uncommon. Commonest causes are Aspergilloma, TB, Bronchiectasis, Endobronchial tumour
• The lung has a dual blood supply - pulmonary and bronchial systems
• Haemoptysis is usually from the Bronchial arterial supply
• This is supplied at systemic pressure by the aorta or intercostal arteries
• The pulmonary system also shunts blood away from hypoxic areas

Causes

• Malignancy: Bronchogenic carcinoma, Secondary lung tumour s. Usually a Smoker. Age >40 years. Opacity on CXR
• Infective: Pneumonia, Lung abscess
• Aspergilloma: CXR shows cavitary lung disease
• Bronchiectasis: Purulent sputum and/or possibly recurrent haemoptysis over years. Cystic lesions on CXR at lung bases. HRCT confirms diagnosis. Bronchiectasis is seen in cystic fibrosis.
• Tuberculosis: Those from Africa and Asia, alcoholic, HIV. Age often <40 years. CXR patchy opacities in the upper lobes
• Trauma, Lung biopsy, Post bronchoscopy
• Vasculitis: Granulomatosis with polyangiitis (Wegener's) cANCA, Goodpasture's syndrome Anti GBM
• Vascular: Pulmonary infarction/embolism. Risk factors for DVT Normal CXR. Acute breathlessness out of proportion to CXR
• Developmental: Pulmonary or bronchial AVM
• Bleeding disorder: Thrombocytopenia, Liver disease, Haemophilia
• Warfarin or Heparin therapy, Mitral stenosis, Facetious

Clinical

• Ask about smoking, weight loss, clubbing, TB, bleeding disorder
• Cystic fibrosis or bronchiectasis
• Massive haemoptysis (> 600 ml/day)

Differential

• Check it is haemoptysis and not epistaxis or another source

Investigations

• Check FBC, U&E, Clotting screen, Arterial blood gas
• CXR can quickly identify the source
• CT with angiography for parenchymal bleeding is best if stable enough
• Bronchoscopy preferably rigid may be useful if bleeding not massive
• cANCA if Granulomatosis with polyangiitis suspected
• Anti-GBM if Goodpasture's suspected

Management of Massive Haemoptysis: Stop bleeding is the key aim and get urgent senior help

• ABC - give O₂ and lie patient on their bleeding side now which allows aeration and protection of good lung. Consider Nebulised Adrenaline [US Epinephrine] 5-10 ml of 1 in 10,000. Reverse any coagulopathy.
• Consider Nebulised Tranexamic acid which has some evidence and was used in post bronchoscopy bleeding or even IV Tranexamic acid and has even been given directly into heavily bleeding lung.
• A portable CXR may give a clue to the side affected and pathology involved
• Often intubated first and then bronchoscopy may be futile in severe cases as blood obscures view if significant and CT is often more useful.
• An endobronchial blocker that is inserted into the airway from which the bleeding is coming may help
• If decompensating need to consider intubation with double-lumen tube.
• Selective intubation of the non-bleeding side main bronchus may be supportive by protecting the bleeding other lung
• Fluid replacement, antitussive, sedation, correct clotting
• Interventional Radiologist may consider Bronchial artery angiography and embolisation should be considered and attempted if possible and a bleeding source has been identified
• Cardiothoracic as surgery indicated in unresponsive cases. Needs to be a treatable cause in a relatively healthy patient.
• If terminal lung cancer then palliation may be more appropriate with Diamorphine/Morphine/Midazolam