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
-
-
- Rigid intubation
- Single-lumen endotracheal intubation
-
-
- 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).
We would love to hear from you. If you should detect any errors, email us customerservice@nysora.com
