Learning objectives
- Describe the definition and possible causes of massive hemoptysis
- Diagnose massive hemoptysis
- Manage massive hemoptysis occurrence
Definition & mechanisms
- Hemoptysis is defined as the expectoration of blood originating from the lower respiratory tract
- There is no agreed definition of massive hemoptysis, with volumes ranging from 100 mL to 1000 mL within 24 hours
- In practice, life-threatening hemoptysis occurs with any volume of blood that could obstruct the airway or cause significant hemodynamic compromise
- Emergency that requires prompt management
Pathophysiology
- In 90% of cases, the source is the bronchial circulation
- causes:
Infectious | Mycobacteria |
Fungal infections (mycetomas) | |
Necrotizing pneumonia and lung abscess (Klebsiella, Pseudomonas, Streptococcus, Actinomyces) | |
Bacterial endocarditis with septic emboli | |
Parasitic (paragonimiasis, hydatid cyst) | |
Parasitic (paragonimiasis, hydatid cyst) | Bronchogenic carcinoma |
Endobronchial tumors (carcinoid, adenoid cystic carcinoma) | |
Pulmonary metastases | |
Sarcoma | |
Pulmonary | Bronchiectasis (including cystic fibrosis) |
Chronic bronchitis | |
Alveolar hemorrhage and underlying causes | |
Diffuse alveolar damage | |
Cardiac/pulmonary vascular | Pulmonary artery aneurysm (rasmussen aneurysm, mycotic, arteritis) |
Bronchial artery aneurysm | |
Pulmonary infarct (embolism) | |
Pulmonary hypertension | |
Congenital cardiac or pulmonary malformations | |
Airway-vascular fistulae | |
Arteriovenous malformations | |
Mitral stenosis | |
Left-ventricular failure | |
Pulmonary veno-occlusive disease | |
Vasculitis/collagen vascular disease | Granulomatosis with polyangiitis |
Goodpasture’s syndrome | |
Behçet’s disease | |
Systemic lupus erythematosus | |
Essential mixed cryoglobulinemia | |
Henoch-Schonlein purpura | |
Mixed connective tissue disease | |
Progressive systemic sclerosis | |
Rheumatoid arthritis | |
Systemic necrotizing vasculitis | |
Immune complex associated glomerulonephritis | |
Pauci-immune glomerulonephritis | |
Hematologic | Coagulopathy (congenital, acquired or iatrogenic) |
Platelet disorders | |
Thrombotic thrombocytopenic purpura | |
Drugs and toxins | Penicillamine |
Solvents | |
Crack cocaine | |
Trimellitic anhydride | |
Bevacizumab | |
Isocyanates | |
Nitrofurantoin | |
Trauma | Catheter-induced pulmonary artery rupture |
Blunt or penetrating chest injury | |
Transtracheal procedures | |
Iatrogenic secondary to interventional pulmonology procedures | |
Bronchoscopic biopsy | |
Miscellaneous | Cryptogenic |
Endometriosis | |
Lymphangiolyomyomatosis | |
Broncholithiasis | |
Foreign body aspiration | |
Lung transplantation | |
Tuberous sclerosis | |
Idiopathic pulmonary hemosiderosis |
Diagnosis
- The main goals are identifying the site of bleeding and revealing the underlying cause
- Diagnostic tools:
- Chest radiography
- Computed tomography
- Fiberoptic bronchoscopy
Management
- Hemoptysis ABCs:
- Bleeding side down (if known bleeding site)
- Intubation
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-
- Rigid intubation
- Single-lumen endotracheal intubation
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- Contralateral isolation and single-lung ventilation
- Volume resuscitation (crystalloids/colloids)
- Multidisciplinary call/page
- Interventional radiology
- ICU
- Interventional pulmonology
- Anesthesiology
- Surgery: Lung resection
Suggested reading
- Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086.
- Thomas, A. and Lynch, G. (2011) Management Of Massive Haemoptysis, WFSA. Available at: https://resources.wfsahq.org/atotw/management-of-massive-haemoptysis/ (Accessed: January 23, 2023).
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