Haemoptysis

OVERVIEW

Haemoptysis

  • Haemoptysis is the symptom of coughing up blood

Massive haemoptysis

  • massive haemoptysis is life-threatening emergency – patients do not usually bleed to death, they asphyxiate
  • massive haemoptysis has no generally accepted definition — suggested volumes range from 100 mL to more than 1000 mL
  • A more relevant definition of massive haemoptysis is the volume that is life threatening by virtue of airway obstruction or blood loss (anatomical dead space is only 100-200 mL)
  • >600 cc in <4 hours associated with much higher mortality (71%)
  • Origin is bronchial circulation in 95% (under systemic pressure), and pulmonary circulation in 5%
  • Alveolar haemorrhage rarely causes massive haemoptysis

CAUSES

“Chronic inflammatory conditions (including bronchiectasis, tuberculosis, lung abscess) and lung malignancies are the most common causes”

TILDA mnemonic

Trachobronchial disorders

  • tracheobronchitis
  • aspiration
  • bronchial adenoma
  • bronchogenic carcinoma
  • bronchial telangiectasia
  • bronchiectasis
  • foreign body aspiration
  • tracheo-oesophageal fistula
  • tracheobronchial trauma

Iatrogenic

  • intubation
  • suction catheters
  • tracheoarterial fistula
  • PA rupture

Localised parenchymal disease

  • pneumonia – all type
  • PE
  • tropical diseases – amebiasis, ascariasis, aspergilloma, coccioidomycosis, – histoplasmosis X
  • metastatic cancer
  • norcardosis
  • lung abscess

Diffuse parenchymal disease

Anticoagulants, DIC, leukaemia, thrombocytopaenia (bleeding diatheses)

Systematic approach

Infections

  • Mycobacteria, particularly tuberculosis
  • Fungal infections (mycetoma)
  • Lung abscess
  • Necrotising pneumonia (Klebsiella, Staphylococcus, Legionella)

Iatrogenic

  • Swan-Ganz catheterisation
  • Bronchoscopy
  • Transbronchial biopsy
  • Transtracheal aspirate

Parasitic

  • Hydatid cyst
  • Paragonimiasis

Trauma

  • Blunt/penetrating injury
  • Suction ulcers
  • Tracheoarterial fistula

Neoplasia

  • Bronchogenic carcinoma
  • Bronchial adenoma
  • Pulmonary metastases
  • Sarcoma

Children

  • Bronchial adenoma
  • Foreign body aspiration
  • Vascular anomalies

Vascular

  • Pulmonary infarct, embolism
  • Mitral stenosis
  • Arteriobronchial fistula
  • Arteriovenous malformations
  • Bronchial telangiectasia
  • Left ventricular failure

Coagulopathy

  • Von Willebrand disease
  • Haemophilia
  • Anticoagulant therapy
  • Thrombocytopenia
  • Platelet dysfunction
  • Disseminated intravascular coagulation

Vasculitis

Pulmonary

  • Bronchiectasis (including cystic fibrosis)
  • Chronic bronchitis
  • Emphysematous bullae

Miscellaneous

  • Lymphangioleiomatosis
  • Catamenial (endometriosis)
  • Pneumoconiosis
  • Broncholith
  • Idiopathic

Spurious

  • Epistaxis
  • Haematemesis

INVESTIGATIONS

Bedside

  • ECG
  • ECHO

Laboratory

  • FBC
  • Coagulation profile

Imaging

  • CXR
  • CT chest
  • ECHO

Special tests

  • bronchoscopy (rigid may be required in bleeding massive)

MANAGEMENT

Goals

  1. maintain airway patency
  2. protect healthy lung
  3. treat cause
  4. fluid resuscitation

Resuscitation

  • bleeding lung side down
  • if both sides bleeding -> place head down
  • isolate lung (rail road ETT into non-bleeding lung with scope or use bougie and DLT)

Specific Therapy

  • treat cause (antibiotics, steroids)
  • correct coagulopathy
  • bronchial artery embolisation
  • bronchoscopic laser photocoagulation
  • iced normal saline lavage of involved lung segments
  • topical adrenaline
  • IV vasopressin
  • surgery

References And Links

LITFL

Journal articles and textbooks

  • Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003 Sep;58(9):814-9. Review. [PMID 12947147] [PMC1746797.]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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