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
- 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
- Malignancy: Bronchogenic carcinoma, Secondary lung tumours. Usually a Smoker. Age >40 years. Opacity on CXR
- Infective: Pneumonia, Lung abscess
- Aspergilloma: CXR shows cavitatory lung disease
- Bronchiectasis: Purulent sputum and/or possibly recurrent haemoptysis over years. Cystic lesions on CXR at lung bases. HRCT conforms 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
- Ask about smoking, weight loss, clubbing, TB, bleeding disorder
- Cystic fibrosis or bronchiectasis
- Massive haemoptysis (> 600 ml/day)
- Check it is haemoptysis and not epistaxis or another source
- 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