Question 2

College Answer

IMMEDIATE MEASURES

a) Protection of airway

b) ETT & Adequate ventilation, consider double lumen tube if site of bleeding known

c) Positioning of patient: Trendelenburg position may allow clearance of blood from airway or if the site of bleeding is known, rt or lt lateral position to keep the bleeding lung dependant

SEARCH FOR CAUSES –

Infections, Tumours, Mitral valve disease, Trauma, pulm vasc disorders, vasculitis, bleeding diatheses

INVESTIGATIONS

H/o and Clinical examination – upper and lower respiratory

CXR/CT Infection

Bleeding and coagulation profiles

Auto-antibody screen

Echo

SPECIFIC TREATMENT

1) Volume replacement

2) Bronchoscopy - ablation of lesions

3) arterial embolisation

4) Surgery

Discussion

• Attention to the ABCS, with management of life-threatening problems simultaneous with a rapid focused examination and a brief history
• Airway
  • Assess the safety of intubation
  • Prepare equipment required for a difficult intubation
  • Access skilled staff to assist
  • Intubate with a dual-lumen tube if it is obvious where the blood is coming from
• Breathing/ventilation
  • High FiO2
  • High PEEP (as a means of putting pressure on the vessel which is bleeding)
  • Humidification, to prevent large dried clots from blocking the bronchi
  • CXR
  • ABG
• Circulatory support
  • Support haemodynamic stability with fluids and inotropes
  • A lower systolic is appropriate, ~ 90mmHg
• Supportive management
  • Sedate and ventilate with mandatory mode; paralysis prevents coughing and further injury to the site of haemoptysis
  • Correct coagulopathy
• Specific management
  • Position the patient in a Trendelenberg position, or with the bleeding lung dependent.
  • Bronchoscopy to remove the larger clots, open airways, and potentially to manage the site of bleeding with cautery
  • Angioembolisation of the site of bleeding
  • Thoracotomy and surgical control of the bleeding

UpToDate has a nice summary of massive hemoptysis

Shigemura, Norihisa, et al. "Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience." The Annals of thoracic surgery87.3 (2009): 849-853.

Reechaipichitkul, Wipa, and Sirikan Latong. "Etiology and treatment outcomes of massive hemoptysis." (2005).