You are asked to assist and help in the emergency management of a 69-year-old who presented to your emergency department with massive haemoptysis.
a) List six major disease categories that cause massive haemoptysis and give one example of each.
b) Outline the emergency management of massive haemoptysis.
College Answer
a) Major disease categories
- Infective – lung abscess, TB, Bronchiectasis, Fungal, Necrotising pneumonia
- Neoplastic - primary or secondaries
- Cardiac – Mitral Stenosis, Congenital heart Disease, Tricuspid Endocardidis
- Vascular – Pulmonary embolism, Pulmonary infaction, Pulm Hxt, AVM
- Systemic Disease – Wegeners, Goodpastures, SLE and other causes of vasculitis
- Haematological – Any severe coagulopathy including acquired causes – DIC, drugs etc
- Iatrogenic/Post Surgical – Swann Ganz, Pulmonary procedures
- Trauma – blunt or penetrating injury, tracheo-innominate artery fistula, ruptured bronchus
b) Emergency management
- Manage ABC, volume resuscitate
- Correct coagulopathy if relevant
- Role of intubation- life- threatening i.e. airway compromise, desaturation or shock. Maybe required if intervention planned
- How to intubate- large size tube (>7.5) if possible so fibre optic bronchoscopy can be performed if needed, single lumen if life threatening, consider double lumen if controlled circumstances and unilateral pathology
- Post intubation- can be nursed lateral decubitus with bleeding lung down to prevent soiling of non-bleeding lung
- Role of bronchoscopy – rigid or flexible – may be needed urgently to place balloon tipped catheter endobronchially to tamponade bleeding
- Bronchial artery embolization- effective non-surgical management
- Surgery- lobectomy or pneumonectomy after resuscitation if other measures fail or not available or for etiologies like A- V malformations, trauma, extensive fungal abscess
- Antimicrobial therapy for underlying infective causes
- Immunosuppression therapy for underlying vasculitis
Discussion
This question interrogates the candidate's ability to form differentials, and then exposes their understanding of pulmonary haemorrhage management.
The list of differentials presented by the college is exhaustive. However, an even more insane list is presented in the article on the role of bronchoscopy in the management of masive haemoptysis. I reproduce this table here:
Causes of Haemoptysis
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Infectious
- Mycobacteria (particularly tuberculosis)
- Fungal infections (including mycetoma)
- Necrotizing pneumonia and lung abscess (Klebsiella pneumoniae, Pseudomonas aeruginosa,Staphylococcus aureus, Streptococcus pneumoniae, other Streptococcus spp. and Actinomyces spp.)
- Bacterial endocarditis with septic emboli
- Parasitic (paragonimiasis, hydatid cyst)
Neoplastic
- Bronchogenic carcinoma
- Endobronchial tumors (carcinoid, adenoid cystic carcinoma)
- Pulmonary metastases
- Sarcoma
Pulmonary
- Bronchiectasis (including cystic fibrosis)
- Chronic bronchitis
- Alveolar hemorrhage and underlying causes
Vascular
- Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic, arteritis)
- Bronchial artery aneurysm
- Pulmonary infarct (embolism)
- Pulmonary hypertension
- Congenital cardiac or pulmonary vascular malformations
- Airway-vascular fistula
- Arteriovenous malformations
- Mitral stenosis
- Left-ventricular failure
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Vasculitis
- Wegener's granulomatosis
- Goodpasture's syndrome
- Behçet's disease
- Systemic lupus erythematosus
Trauma
- Induced by diagnostic bronchoscopy (brushing/biopsy)
- Related to interventional pulmonology procedures (dilation, metallic stent placement, high-dose brachytherapy)
- Catheter-induced PA rupture
- Blunt or penetrating chest injury
- Transtracheal procedures
Hematological
- Coagulopathy (congenital, acquired or iatrogenic)
- Platelet disorders
Drugs and toxins
- Penicillamine
- Solvents
- Crack cocaine
- Trimellitic anhydride
- Bevacizumab
Miscellaneous
- Endometriosis
- Lymphangioleiomatosis
- Broncholithiasis
- Cryptogenic
- Foreign body aspiration
- Lung transplantation
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As for the management: the college answer is complete but could be arranged in a more eye-pleasing fashion.
1) Control the airway.
- Intubate the patient with a large-bore tube to permit bronchoscopy
- If you are skilled and the pathology is unilateral, a dual-lumen tube could be considered
2) Control the breathing.
- Ventilate the patient with the bad lung dependent, to prevent contralateral lung soiling.
- Increase the PEEP, to get the benefit of whatever tamponade effect it might provide.
3) Control the circulation.
- Replace the lost blood and stabilise the hemodynamic variables
4) Control the bleeding
- Reverse any coagulopathy
- Perform bronchoscopy
- Suck out any obvious clots
- Place a balloon-tipped catheter to put pressure on the bleeder
- Burn the bleeder with argon plasma (if you have the tools)
- Perform angio-embolisation if bleeding is not controlled
- Send the patient to thoracotomy if angio-embolisation is impossible
5) Control the cause
- Antibiotics for tuberculosis and fungal abscesses
- Surgery or radiotherapy for cancers
- Immunosuppression for vasculitis
- Surgery for AVMs
Angio-embolisation is a pretty cool modality, with a low complication rate.