Haemoptysis and generic bleeding from the airway has come up a couple of times in this exam.
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.
Infectious
Neoplastic
Pulmonary
Vascular
|
Vasculitis
Trauma
Hematological
Drugs and toxins
Miscellaneous
|
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".
Question 16 from the second paper of 2022 asked the candidates tto "list the investigations that will assist with localizing the site of bleeding".
Unlike the dislodged tracheostomy or the patient suddenly impossible to ventilate, this thing does not have an agreed-upon algorithm of management. The brief summary of sensible-sounding management steps seen in the discussion section for Question 2 from the first paper of 2012 is offered here in lieu of anything more official:
1) Control the airway.
2) Control the breathing.
3) Control the circulation.
4) Control the bleeding
5) Control the cause
Now, let's say, as in Question 16 from the second paper of 2022, that a single source of bleeding has been identified. What are your management options? A whole series of possibilities presents itself. Davidson & Shojaee (2020) have an excellent paper that details some of these options. This also permits an exploration of an alternative approach to the answer, worded and structured slightly differently. Below, the options are presented in order of both priority and invasiveness
1) Achieve lung isolation
2) Trial conservative management: some patients may improve (apparently, up to 17%, according to Valipour et al, 2005)
3) Interventional bronchoscopy techniques involve usually the obliteration of the bleeding site or the occlusion of the mucosa. Options include:
4) Rigid bronchoscopy should probably be mentioned, mainly because the examiners had complained about it in their comments to Question 16 from the second paper of 2022. In case the reader is wondering what the difference is, a rigid bronchoscope is a hollow metal tube which is introduced into the trachea instead of an endotracheal tube, rather than through it, and which does not have any of the advantages of the latter (i.e. it is not cuffed, does not ventilate beyond simple gas insufflation, and cannot offer controlled positive pressure). Of course the counterargument here is that a normal bronchoscopic swivel adaptor leaks horribly anyway, so what pressure and ventilation are you really getting? Anyway: access for instruments is the main advantage, and apart from ventilation the main disadvantage is the inability to reach upper lobe bronchi and more distal structures. Technques made available mainly via the rigid bronchoscope include:
Of these, size is the most important thing, as electrocautery and plasma are only limited by rapidly evolving flexible bronchoscope technology
5) Interventional radiology is mainly involved for bronchial artery embolisation. Coils, foam, glue, and tiny PVC particles have all been used. There is probably little else to discuss here other than to say that this technique is powerless to limit the damage from pulmonary arterial or venous bleeding.
6) Surgery is the last option, as it would usually be performed in an emergency and would usually result in severe morbidity. Lobectomy and pneumonectomy are often required, and the mortality rate for emergency procedures is quoted as 34%. This is the only option for pulmonary arterial or venous bleeding, and probably the preferred option for malignancies and large abscesses.
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Ibrahim, W. H. "Massive haemoptysis: the definition should be revised." European Respiratory Journal 32.4 (2008): 1131-1132.
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Amirana, M., et al. "An Aggressive Surgical Approach to Significant Hemoptysis in Patients with Pulmonary Tuberculosis 1, 2, 3." American Review of Respiratory Disease 97.2 (1968): 187-192.
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Davidson, Kevin, and Samira Shojaee. "Managing massive hemoptysis." Chest 157.1 (2020): 77-88.
Wand, Ori, et al. "Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial." Chest 154.6 (2018): 1379-1384.
Cutshall, Danica M., Brannon L. Inman, and Melissa Myers. "Treatment of Massive Hemoptysis with Repeated Doses of Nebulized Tranexamic Acid." Cureus 14.9 (2022).
Thomas, Angela, and Gerry Lynch. "Management of massive haemoptysis." (2011).
Venkatesh, A. N., and H. Rajanna. "MANAGEMENT OF HEMOPTYSIS IN EMERGENCY ROOM." Вестник экстренной медицины 14.1 (2021): 44-50.
McKee, Andrew. "Massive Hemoptysis." Cardiothoracic Critical Care E-Book (2007): 392.
Haponik, Edward F., Alan Fein, and Robert Chin. "Managing life-threatening hemoptysis: has anything really changed?." Chest 118.5 (2000): 1431-1435.
Sampsonas, F., et al. "Bronchoscopic, non-interventional management of hemoptysis in resource limited settings: insights from the literature." Eur Rev Med Pharmacol Sci 24.7 (2020): 3965-3967.
Valipour, Arschang, et al. "Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis." Chest 127.6 (2005): 2113-2118.
Sakr, L., and H. Dutau. "Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management." Respiration 80.1 (2010): 38-58.