Massive Haemoptysis

This is an anaesthetic crisis
Priority is to: * Decontaminate the airway * Maintain oxygenation

Large haemorrhage into the pulmonary tree which:

• Is variably defined as 100-1000mL of haemoptysis/day
• May precipitate cardiac arrest secondary to hypoxia

##Emergency Management

Immediately:

• Protect airway
  • Large, single-lumen ETT
    • Suction catheter/bronchoscopic decontamination
  • Consider lung isolation
    • Bronchial blocker
      
      • May be passed outside the ETT and placed under bronchoscopic guidance
      • Consider use of a 14Fr Fogarty catheter
    • Endobronchial tube
• Haemodynamic resuscitation
  
  • Cardiac arrest is common
  • Hypoxia is almost always the cause
  • Hypovolaemia is rarely significant

Definitive treatment:

• Source control
  Options include:
  • Rigid bronchoscopy
  • Interventional angiography
    Bronchial angiography and embolisation.
    
    • Note risk of paralysis due to loss of spinal perfusion
  • Thoracotomy
• Correction of coagulopathy

Epidemiology and Risk Factors

Pathophysiology

• 90% of haemorrhage comes from the bronchial circulation
  These bleeds are dependent on systemic blood pressure.

Aetiology

Causes can be divided into:

• Airway
• Trauma
  • Suction
  • Foreign body
  • Tracheo-arterial fistula
  • Blunt/penetrating
• Primary lung disease
  • Infective
    • Mycobacterial
    • Fungal
    • Lung abscess
    • Parasitic
      • Hydatid cyst
      • Paragonimiasis
    • Necrotising pneumonia
      Staphylococcus, Klebsiella, Legionella.
  • Neoplasm
    • Primary
    • Metastases
    • Sarcoma
• Cardiac
  • LV failure
  • Mitral stenosis
• Vascular
  • Vasculitis
    • Wegener’s granulomatosis
    • Behcet’s disease
  • Vascular
    • AVM
    • PE
• Coagulopathy
  • von Willebrand’s Disease
  • Haemophilias
  • Anticoagulants
  • Thrombocytopenia
• Iatrogenic
  • PAC
  • Bronchoscopy
  • Biopsy
  • Transtracheal aspiration

Clinical Manifestations

History

Examination

Diagnostic Approach and DDx

Investigations

Management

Medical:

• If related to PAC:
  Withdraw catheter slightly and reinflate to provide proximal compression, prior to surgical resection.

Interventional:

• Bronchial artery embolisation
  • Used for life-threatening haemoptysis
  • Failure in up to 10%
• Surgical resection
  Treatment of choice when site is localised and patient can tolerate resection.

Anaesthetic Considerations

Marginal and Ineffective Therapies

Complications

Prognosis

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References

1. Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care • Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003 Sep 1;58(9):814–9.