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
- Viral pneumonitis
- scleroderma
- vasculitidies – Goodpastures, SLE, GPA
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
- Behcet’s disease
- Granulomatosis with polyangiitis (GPA)
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
- maintain airway patency
- protect healthy lung
- treat cause
- 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
CCC Ventilation Series
Modes: Adaptive Support Ventilation (ASV), Airway Pressure Release Ventilation (APRV), High Frequency Oscillation Ventilation (HFOV), High Frequency Ventilation (HFV), Modes of ventilation, Non-Invasive Ventilation (NIV), Spontaneous breathing and mechanical ventilation
Conditions: Acute Respiratory Distress Syndrome (ARDS), ARDS Definitions, ARDS Literature Summaries, Asthma, Bronchopleural Fistula, Burns, Oxygenation and Ventilation, COPD, Haemoptysis, Improving Oxygenation in ARDS, NIV and Asthma, NIV and the Critically Ill, Ventilator Induced Lung Injury (VILI), Volutrauma
Strategies: ARDSnet Ventilation, Open lung approach, Oxygen Saturation Targets, Protective Lung Ventilation, Recruitment manoeuvres in ARDS, Sedation pauses, Selective Lung Ventilation
Adjuncts: Adjunctive Respiratory Therapies, ECMO Overview, Heliox, Neuromuscular blockade in ARDS, Prone positioning and Mechanical Ventilation
Situations: Cuff leak, Difficulty weaning, High Airway Pressures, Post-Intubation Care, Post-intubation hypoxia
Troubleshooting: Autotriggering of the ventilator, High airway and alveolar pressures / pressure alarm, Ventilator Dyssynchrony
Investigation / Indices: A-a gradient, Capnography and waveforms, Electrical Impedance Tomography, Indices that predict difficult weaning, PaO2/FiO2 Ratio (PF), Transpulmonary pressure (TPP)
Extubation: Cuff Leak Test, Extubation Assessment in ED, Extubation Assessment in ICU, NIV for weaning, Post-Extubation Stridor, Spontaneous breathing trial, Unplanned extubation, Weaning from mechanical ventilation
Core Knowledge: Basics of Mechanical Ventilation, Driving Pressure, Dynamic pressure-volume loops, flow versus time graph, flow volume loops, Indications and complications, Intrinsic PEEP (autoPEEP), Oxygen Haemoglobin Dissociation Curve, Positive End Expiratory Pressure (PEEP), Pulmonary Mechanics, Pressure Vs Time Graph, Pressure vs Volume Loop, Setting up a ventilator, Ventilator waveform analysis, Volume vs time graph
Equipment: Capnography and CO2 Detector, Heat and Moisture Exchanger (HME), Ideal helicopter ventilator, Wet Circuit
MISC: Sedation in ICU, Ventilation literature summaries
LITFL
- CCC – Massive haemoptysis DDx
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.]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC