Causes and management of massive haemoptysis

Haemoptysis and generic bleeding from the airway has come up a couple of times in this exam. Question 2 from the first paper of 2012 asks specifically for possible causes and management in a guy who presents via the ED (i.e. it could be anything). Question 7 from the first paper of 2017 also asked for a list of possible causes, except this time the airway bleeding is from a recently fashioned tracheostomy, and you can't call it "haemoptysis" because strictly speaking the Greek word "ptusis" means "to spit", and the trache patient's bloody cough is bypassing the mouth and lips.

A huge list of differentials for the causes of haemoptysis is presented by the college in their model answer to Question 2 from the first paper of 2012. An even larger list is presented in the article on the role of bronchoscopy in the management of massive haemoptysis. I reproduce this table here.

You call that "massive"?

Critical care literature is rarely given to pointless hyperbolae, and the use of words like "massive" or "catastrophic" is usually reserved for colloquial descriptions rather than precise clinical definitions. This also seems to be the case here. How much is "massive", and can you really ever quantify the volume of expectorated blood? It tends to go everywhere, it's not as if the patient is carefully depositing it into a measuring jug.

Historically, valiant efforts to hold that jug have been made. A great many article incorrectly reference Amirana et al (1968) as the origins of a low-volume definition for massive haemoptysis. These investigators reported on a series of TB patients from the 1960s, but did not get over-excited with his terminology - they described it as "significant" haemoptysis when their patient coughed up a total of 100ml per day. This volume was correctly described, as it hardly seems worthy of the term "massive".  At the other end of the spectrum,  a highly cited article by Corey et al (1987) instead suggests a volume of 1000ml over 24 hours, which seems better suited to descriptors like  "colossal" or "spectacular".

Of course, all these definitions are totally pointless. The LITFL article on haemoptysis wisely points out that definitions based on volume are meaningless in terms of defining "massiveness", as the more important issue is how life-threatening it is (by virtue of airway obstruction). In this case haemoptysis coming from the tracheostomy patient in Question 7 from the first paper of 2017 could be life-threatening with only 4ml of blood (that is the internal volume of a 8.0mm non-adjustable percutaneous tracheostomy tube). Rate of blood loss must also be viewed as important, as the loss of 1000ml over 24 hours may be better tolerated than the the loss of 1000ml over fifteen seconds. These considerations had prompted a certain W.H. Ibrahim to write a letter to the editor of European respiratory Journal, calling for an introduction of the term "life-threatening haemoptysis", as this might  "provide a fascinating and rich understanding of the condition".

Management of massive haemoptysis

Again, this is the same as the management outlined in  Question 2 from the first paper of 2012.

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
• Position the patient in a Trendelenberg position, or with the bleeding lung dependent.

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. Angio-embolisation is a pretty cool modality, with a low complication rate.
• 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