massive hemoptysis
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D. P. Laporta MDD. P. Laporta MD
Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital
McGill University
presented to McGill Residentspresented to McGill ResidentsCritical Care (January 2000)Pulmonary (July July 2000
MASSIVE HEMOPTYSIS
REFERENCES
•Bone: Pulmonary & Critical Care Medicine, 1998 ed., 1998 Mosby-Year Book, Inc.Ch R19 Massive HemoptysisCh M10 Pulmonary Hemorrhage Syndromes
•Jean Baptiste E «clinical Assessment and management of massive hemoptysis Crit Care Med 2000; 28:1642-7
•Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis, in : Flexible bronchoscopy in the 21st century. Clin. Chest Med. 1999; 20(1) March
•White R. Jr. Bronchial Artery Embolotherapy for Control of Acute Hemoptysis. Analysis of Outcome . Chest 1999; 115(4) April
•Fanburg BL et al, Case 52-1993: A 17-Year-Old Girl with Massive Hemoptysis and Acute Oliguric Renal Failure. NEJM Weekly CPC. 1993; 329(27)
MASSIVE HEMOPTYSIS
Definition
Natural History
InvestigationsCXRFOBCTOthers: echo , V/Q, Duplex, Pulm Angio,Bloodwork
InterventionsMedical: conservative, BAESurgical
HEMOPTYSIS
USUAL HEMOPTYSIS Frequent Life Frightening
1% to 14% of all patients with hemoptysis
MASSIVE HEMOPTYSIS Rare ( 1-14 % of pts with H) Life Threatening
one of the most frightening of medical emergencies …for patient and physician !!!
CHALLENGE: explosive clinical presentation
MAJOR RISK: impending asphyxiation
need to respond quickly and appropriately
MASSIVE HEMOPTYSIS
NATURAL HISTORY AND PROGNOSIS
MORTALITY
Immediate : 7% of 113 patients who presented with massive hemoptysis died soon after onset.
Etiology : TB 18.6%, CF 32%, Other 10% DURATION
If survive the initial episode, bleeding stops <3-6 days
RECURRENCE RATE
20-46% after bronchial embolization
MASSIVE HEMOPTYSIS
Prognostic Features Associated with Death • bleeding exceeding 1000 mL/24 h
600 mL of hemoptysis in <4 hours 71%mortality4-16 hous 22% 16-48 hours 5%
• hemodynamic instability• CXR evidence of aspiration • bilateral bleeding sources• inability to localize source of bleeding
• caused by a neoplasm• inadequate pulmonary function• debilitated states, and metastatic cancer
• MORTALITY 80 % if > 1L/24 h PLUS malignancy
MASSIVE HEMOPTYSIS
DEFINITIONS
> 100 mL/24 hrs
> 200 mL/24 hrs
> 300 mL/24 hrs
600 mL/24 hrs
> 1000 mL/24 hrs
OverestimateOverestimate
UnderestimateUnderestimate
400 ml = abN gas XC
Hemoptysis: is it real ?
GIFactitious (Munchausen ’s)Pseudo: drugs (RFP, clofazimine)Serratia pneumoniaENT
MASSIVE HEMOPTYSIS
SOURCES OF HEMOPTYSIS
2 interconnected circulations :
pulmonary (low pressure)
bronchial (systemic pressure)- proximal airways (trachea and
main stem bronchi) …RA
- peripheral airways/parenchyma…bronchopulmonaryanastomoses (r-l shunt)…pulmonary veins…LA
Bronchial Circulation
Come directly or indirectly from the aorta (T3-8)
VariabilityVariability
NonbronchialNonbronchial systemic collateral arteries
in 45% of patients with hemoptysis
commonly: intercostal, subclavian, axillary & phrenics
uncommonly: IMA, thyrocervical, carotid, coronaries
Because of the many systemic arteries involved, routine arteriographic localization cannot be all-inclusive
MASSIVE HEMOPTYSIS ETIOLOGY (1)
Infectious (bacterial, mycobacterial, viral, fungal, parasitic)
Lung abscess
Bronchiectasis (including cystic fibrosis)
Mycetoma (e.g., aspergilloma)
Infected BP Sequestration
Septic emboli
Infected aortic graft
NeoplasmMalignant Bronchogenic
Metastasis from pulmonary/extrapulmonary
Benign (bronchial adenoma)
MASSIVE HEMOPTYSIS ETIOLOGY (2)
Foreign body/traumaAspirated foreign bodyBroncholithTracheovascular fistulaTrauma, Brachytherapy, Laser
Cardiac/pulmonary vascularPulmonary venous HTN
Mitral stenosis, PVOD
(Pulmonary embolus)Pulmonary artery
Perforation (complicating Swan-Ganz catheter)Aneurysm/false (mycotic, Behcet’s, Hughes-Stovin)
Arteriovenous malformations
OWR, DieuLaFoye
Fistulae (every vessel parring through the thorax)
MASSIVE HEMOPTYSIS ETIOLOGY (3)
Alveolar hemorrhage
Goodpasture's syndrome
Systemic vasculitides/collagen vascular diseases…capillaritisBehcet's syndromeEssential mixed cryoglobulinemia, Henoch-Schonlein purpuraProgressive systemic sclerosisRheumatoid arthritis, Systemic lupus erythematosus, Mixed connective tissue disease Systemic necrotizing vasculitis, Wegener's granulomatosis
Other Glomerulonephritis
Immune complex associated glomerulonephritisPauci-immune glomerulonephritis
Familial
Acute Leukemias
MASSIVE HEMOPTYSIS ETIOLOGY (4)
Drug-induced
Cocaine, D-penicillamine, Isocyanates, Nitrofurantoin, Trimellitic anhydride
Anticoags, Thrombolytics, ASA
MASSIVE HEMOPTYSIS ETIOLOGY (4)
Miscellaneous• Idiopathic hemosiderosis • Coagulation disorders
Thrombotic thrombocytopenic purpuraDIC
Acquired coagulopathy (permissive)• Endometriosis (Catamenial hemoptysis)• Sarcoidosis • Lymphangioleiomyomatosis
• Chronic Lung Disease– Emphysematous bullae
– Pneumoconiosis
MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS BEDSIDE ASSESSMENT BEDSIDE ASSESSMENT
OF THE PATIENTOF THE PATIENT
• Clubbing, Simian crease, Cutaneous nodules/pustules + uveitis
• IVDU with septic thrombophlebitis, palpable purpura, malar rash
• Oral: ulcers, mucosal telangiectasias,
• Post-URI rhinitis, saddle nose
• Stridor/wheezing
MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History
Young adult female ...Young adult female ...
• otherwise healthy• with recurrent CHF & A fib
• with spontaneous pneumothorax + ILD
• menstruating
MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History
Inflammatory Lung DiseasesInflammatory Lung Diseases
• bronchiectasis
• abscess
• necrotizing pneumonia
• infected cavity/bulla (mycetoma)
MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History
TUBERCULOSISmore common in the presence of cavitary
disease.
pathologic lesions Rasmussen's aneurysms bronchial artery erosions from tb airway
inflammation or bronchiectasis; secondary infections of prior tuberculous
cavities (eg Aspergillus)
Specific clinical situations Specific clinical situations
presenting with presenting with
MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS
TracheostomyPost-Partum
Southeast Asia, Middle East South AmericaLymphoma
Acute LeukemiaCardiac Surgery
High-power magnification showing capillaritis,
which is characterized by infiltration of the alveolar septae
by neutrophils (arrow). Note the presence of scattered red cells
in the parenchyma (H&E stain, original magnification × 400).
DIFFUSE ALVEOLAR HEMORRHAGE
Bloody BAL fluidhemosiderin-laden macrophageslack of infectious pathogens
...are sufficient to establish DAH.
Causes of MH Associated With aCauses of MH Associated With a Normal Chest Radiograph Normal Chest Radiograph
BronchiectasisPulmonary embolismLung carcinoma in the trachea or large airwaysPulmonary artery dissection or rupture
MANAGEMENT of MHMANAGEMENT of MH
1. Make the right etiological DIAGNOSIS ! Hx. Px, Sputum, Bloods, FOB, Imaging
2. Determine the SITE of bleeding Hx, Px, CXR (?CT) FOB : flexible, rigid
• observe mucosa etc., washings: culture incl TB, cytology
3. Airway control/pt stabilizationsurgical candidate ?
4. Specific Therapy
STEP SPECIFICRECOMMENDATIONS/OPTIONS
COMMENTS/RATIONALE
(1) PROTECT AIRWAY AND STABILIZE PATIENT
Admit and monitor Intensive care unit Allows close monitoring ofhemodynamics and magnitude ofblood loss
Maintain adequateairway
Size 8 endotracheal tube To facilitatesuctioning/bronchoscopy
Consider double lumen tube
Consider unilateral intubation Bronchoscopy can help verifyplacement
Supplementaloxygen
Correctcoagulopathy
Blood, fresh frozen plasma
Fluid resuscitationConsider intravenous vasopressin
Stool softenersPrevent straining
Cough suppressants
Lateralize bleeding Bleeding lung down
If bleeding lateralized rather than localized:
A right-sided bleeding : B left-sided bleedingL lung selectively intubated trachea intubated over bronchoscope firstOver the bronchoscope. with the patient in the left lateral position to
minimize aspiration14Fr 100 cm Fogarty catheter passed through thevocal cords beside the endotracheal tube to a levelseveral centimeters below the cuff.
DOUBLE LUMEN ETT FOR ENDOBRONCHIAL TAMPONADE.
bronchial lumen: placed in L main bronchus to ventilate L lung
tracheal lumen: remains supracarinal to ventilate R lungand prevents occlusion of the RUL orifice.
external lumina connected to ventilator using a "Y" connector device.
Left and right-sided double lumen tubes are currently available.
DOUBLE-LUMEN ETT IN DOUBLE-LUMEN ETT IN MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS
Requires expertSmall lumina : difficult insertion, easy obstruction
62 patients with MH• 4/7 pts with DL-ETT : aspiration and death
• cause : loss of tube position and pulmonary aspiration during surgery.
• L bronchial ETI : 0/12 deaths from
• L Fogarty- Tracheal ETI : aspiration
(2) LOCALIZE THESOURCE OF BLEEDING
Hx, Px
Radiology CXR
Bronchoscopy Flexible
Rigid
Early bronchoscopy helpsidentify exact location andguide further management
LIMITATIONS: Upper lobes Peripheral disease
TIMINGTIMINGOF BRONCHOSCOPYOF BRONCHOSCOPY
The The sicker,sicker, the the earlierearlier ! !
site of bleeding visualized more commonly with early bronchoscopy (within 48 hours)
unlikely relevant in non-massive hemoptysis
(3) ADMINISTER SPECIFIC THERAPY
Bronchoscopictherapies
Iced saline lavage
Topical agents Epinephrine, thrombin, thrombin-fibrinogen
Endobronchialtamponade
Size 4 to 7 French catheter, J-wire(through nostril), bronchus blocker
Laserphotocoagulation
For endobronchial lesions
Pharmacologic Rxs Vasopressin
Tranexamic acid
Systemic steroids In cases of alveolar hemorrhage
GnRH/danazol In catamenial hemoptysis
Antibiotics/anti-TB/anti-fungals
In cases of suspected or known infection
Angiography andembolization
Standard/superselective
Semidefinitive therapy, or bridge tosurgery
Radiation therapy In aspergillomas and vascular tumors
Surgical resection(ifpulmonary functionallows)
CavernostomySegmentectomyLobectomy2Pneumonectomy
If embolization not feasible (unavailable,technically impossible, or did not stopbleeding), patient too unstable to wait forangiogram, or cause of hemoptysis notlikely to benefit from embolization (PAperforation, ruptured mycetoma)
Role of bronchoscopy is presented in bold typeface.
Management of MHManagement of MH
BRONCHIAL ARTERY EMBOLIZATION (1)BRONCHIAL ARTERY EMBOLIZATION (1)
successful immediate control 64% to100%. Technical inability to cannulate : 13% Recurrence of bleeding
• Immediate 20-40%
• Follow-up post BAE 1 year: 16 % 3 years : 23% Complications :
• vessel perforation/intimal tears
• sequelae of bronchial artery occlusion (e.g., chest pain, fever, hemoptysis)
• inadvertent ectopic emboli.
• mesenteric occlusion
• vessels supplying the extremities
• ASA embolization reduced withcoaxial microcatheter system :"superselective" ba
catheterization/bae without occluding other branches
Management of MHManagement of MH
BRONCHIAL ARTERY EMBOLIZATION (2)BRONCHIAL ARTERY EMBOLIZATION (2)
most difficult : identify the vessel(s) responsible for bleeding.
injection in the descending aorta just below the left subclavian artery
may require a full-arch aortogram in some LL bleeding w/no apparent bronchial supply: UL bleeding: unilateral subclavian artery injection
to exclude nonbronchial systemic collateral arteries.
formal bronchial arteriogram blush,abnormal vessels, ensures that no
communication to the anterior spinal artery
Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?
Observational studies no RCTs… selection bias none used bae as part of medical therapy wide range of mortality rates :
• surgical (1-50%) and medical (1.6-85%) results are mixed …lower surgical
mortality rates
Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?Current recommendationsCurrent recommendations : surgical resection preferred if:
BAE unavailable or failed imminent survival threatened by transport to radiology (ABCs) surgically operable patient with a localized (ie resectable) lesion as
cause of MH which is deemed unlikely to be controlled by BAE:
– Thoracic vascular injury/trauma
– mycetoma +profuse collateral arterial supply,
– hydatid cyst
– bronchial adenoma
– AVM
PA RUPTURE PA RUPTURE (1) Epidemiology Prevalence .06-.2% Rebleed: 90 % within 3 days Mechanism:
Pseudoaneurysm (Psan) Mortality:
all comers 45-65%
if rebleed: 40-70%
26% if abnormal CXR is only manifest'n of PA rupture
65% if clinical hemorrhage (ie hemoptysis, hemothorax, parenchymal bleed - HHPB)
CXR may be normal despite PA rupture ? Psan
PA RUPTURE PA RUPTURE (2)
Contributory causes technical errors (improper equipment, technique or
judgment) age > 60PA hypertensionanticoagulatedhypothermia inhalational anesthetic agentsperi-CPB (especially intraop)
SUSPECTED PA RUPTUREHEMORRHAGE (HHPB) OR
NEW PULMONARY INFILTRATE RIGHT AFTER PAC INSERTION
pull back PAC !
EmergencyResuscitation-Management:ABC !
HEMOPTYSISBronchoscopeDouble-lumen ETTEndobronchial ETT
HEMOTHORAX
CONSIDERlung resection
If PatientSurvives
Infused CT
Dx pseudoaneurysm
CONSIDERtherapeutic angiolung resection
IN OR
HEMOPTYSIS
(see column 1)
if massive: resume CPBbefore maneuvers
CONSIDERlung resection
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