1Departments of Cardiothoracic Anaesthesia and Intensive Care, 2Cardiothoracic Surgery and 3Thoracic Radiology, Linköping Heart Center, University Hospital, SE-581 85 Linköping, Sweden*Corresponding author
Accepted for publication: October 10, 2001
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Br J Anaesth 2002; 88: 2915
Keywords: arteries, aortic aneurysm; blood, massive haemoptysis; lung, angiectasia; monitoring, bronchial arteriography; surgery, bronchoscopy
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case reports |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
The patient was transferred to the University Hospital. Upon admission she was haemodynamically stable but presented with an arterial oxygen saturation of 70%. Fibreoptic bronchoscopy was repeated to clear the airways of blood and clots, and to localize the source of bleeding. A slightly elevated bluish structure in the right main stem bronchus was found, which was thought to be a vascular malformation. After intrabronchial infusion of epinephrine, tranexamic acid and iced saline lavage, the bleeding diminished. Thereafter a left-sided double-lumen tube (Broncho-Cath, Mallinckrodt Medical Ltd, Athlone, Ireland) was sited (Fig. 3). To reduce the risk of re-bleeding, the patient also received desmopressin and tranexamic acid systemically.
|
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The definition of massive haemoptysis varies from 100 to 600 ml of blood loss per 24 h.14 68 In our opinion, quantification of haemoptysis may be difficult and, from a clinical point of view, such criteria are not useful. Obviously, haemoptysis that jeopardizes respiratory function should be treated as a medical emergency.
Initial management
The first priorities in treating the patient with life-threatening haemoptysis are to maintain the airway, optimize oxygenation and stabilize the haemodynamic status. Intubation with a single-lumen endotracheal tube is recommended until the bleeding is localized. In patients with lateralized or localized persistent bleeding, immediate control of the airway may be achieved by insertion of a double-lumen endobronchial tube to isolate and ventilate the lungs separately, or by endobronchial tamponade with, for instance, a Fogarty catheter.7 912
Selective main-stem intubation into the uninvolved bronchus to protect the contralateral side is an alternative to the double-lumen tube if the bleeding side is known. However, with this method there is loss of access to the side of bleeding for suctioning and bronchoscopic examination. The need to clear the airways of blood and clots should influence the decision in the choice of tubes, as clearance of blood is more difficult through the double-lumen tube. Furthermore, a normal fibreoptic bronchoscope cannot be introduced through a double-lumen tube and the risk of occlusion by clots must be considered. Our second patient first received a single-lumen endotracheal tube and later, when the bleeding source had been identified, a double-lumen tube was introduced.
When the side of bleeding is identified it is generally accepted that the patient should be placed with the bleeding side down to prevent aspiration into the uninvolved lung. Systemic therapy directed at improving coagulation deserves consideration. Also, bronchoscopy may be useful for topical haemostatic treatment.13
Diagnostic procedures
Occasionally in life-threatening haemoptysis the treatment has to be based on presumptive, rather than conclusive, diagnosis. It is essential to achieve early identification of which lung or lobe/segment is the source of bleeding.
Bronchoscopy, preferably during active bleeding, should be performed to lateralize the bleeding side, to identify the part of the lung that may have to be urgently excised and, if possible, to identify the cause of the bleeding.7 Rigid bronchoscopy obviously provides better scope for suctioning but does not generally allow visualization of upper lobes and peripheral lesions. The two methods of bronchoscopy can be used in conjunction with one another by passing the fibreoptic bronchoscope through the rigid instrument.7 In our first patient, the bleeding lung was identified by means of fibreoptic bronchoscopy; in the second, a presumptive diagnosis was made at the second attempt. Major ongoing bleeding in the lungs can render it impossible to identify or even lateralize the bleeding with fibreoptic bronchoscopy. In both patients, however, fibreoptic bronchoscopy contributed to the successful management of the respiratory tract. The choice of bronchoscopy method depends not only on the situation of the patients but is also influenced by availability of special equipment and expertise. Both our patients were intubated. We therefore considered it advisable to use fibreoptic bronchoscopy. Furthermore, fibreoptic bronchoscopy can be performed at the patients bedside. However, as mentioned earlier, the availability of expertise determines the method in the immediate management of these patients. Use of the rigid bronchoscope is declining and fewer institutions are now providing training in this technique.7 Repeated fibreoptic bronchoscopy with instillation of cold epinephrinesaline in intubated patients with life-threatening haemoptysis was successful in 6 out of 7 patients.13
Chest radiography and CT scan are also useful diagnostic tools. In our first patient a CT scan demonstrated an aneurysm of the descending aorta that had ruptured into the left lung (Fig. 2). However, the site of intra-bronchial haemorrhage is localized with reasonable confidence in only 63% by a combination of these diagnostic techniques.1
The lungs have a dual vascular supply, being served by both the pulmonary and bronchial circulations. Selective bronchial arteriography is an important diagnostic technique with therapeutic applications in these cases.14 In our second patient, bronchial arteriography confirmed the suspicion of a vascular malformation. Occasionally, pulmonary angiography has to be considered, such as in suspected pulmonary embolism or Rasmussens aneurysm.15 16
Echocardiography may reveal rare cardiac causes of massive haemoptysis such as bacterial endocarditis or mitral stenosis.17 18 Infectious, vasculitic and other systemic diseases should not be overlooked in the search for the cause of bleeding.1 2 19
Causes and treatment
Outside the Western world, tuberculosis remains the most common cause of massive haemoptysis.1 The majority of the patients have bronchiectasias or cavitation. In Western countries, however, neoplastic disease of the lung is the most common cause of massive haemoptysis.6 Other major causes of massive haemoptysis include aspergilloma and bronchiectasias.6 20
A history of haemoptysis in association with menstruation suggests pulmonary endometriosis.21 Haemoptysis in the early postoperative period should suggest the possibility of injury to the pulmonary vessels by a SwanGanz catheter.11 22 Haemoptysis may occur as a late complication of surgical procedures such as pseudoaneurysms after aortic graft surgery or because of retained foreign bodies after pulmonary procedures.23 24
Definitive treatment depends on the cause and anatomical localization of massive haemoptysis. As in our first patient, bleeding from large systemic arteries and aneurysms into the bronchial tree necessitate immediate surgery.17 25 26 Endovascular stents may provide an alternative to surgery in selected cases.23 Bleeding from bronchial or other small systemic arteries is treated preferably by selective embolization, as was attempted in our second patient.14 27 A thorough understanding of bronchial arterial anatomy is required to avoid potential complications, in particular transverse myelitis.28 29 Immediate control of haemoptysis by bronchial artery embolization has been reported in between 75% and 90% of patients.14
In conclusion, massive haemoptysis should be considered as a life-threatening medical emergency. A well co-ordinated strategy involving different medical and surgical specialists is required for successful management. Control of the respiratory tract is the first priority and should be followed by aggressive measures to identify the source of bleeding, and prompt treatment. Because of the high incidence of recurrent haemoptysis, these patients should not be discharged from hospital before the definitive diagnosis and, if possible, definitive treatment.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Conlan AA, Hurtwitz SS, Krige L, Nicolaou N, Pool R. Massive hemoptysis. Review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 1204[Abstract]
3 Corey R, Hla KM. Major and massive hemoptysis: reassessment of conservative management. Am J Med Sci 1987; 294: 3019[ISI][Medline]
4 Cahill BC, Ingbar DH. Massive hemoptysis: assessment and management. Clin Chest Med 1994; 15: 14768[ISI][Medline]
5 Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation and therapy for massive hemoptysis. Clin Chest Med 1992; 13: 6982[ISI][Medline]
6 Winter SM, Ingbar DH. Massive hemoptysis: pathogenesis and management. J Intensive Care Med 1988; 3: 17188
7 Sternbach G, Varon J. Massive haemoptysis. Intensive Care World 1995; 12: 748
8 Crocco JA, Rooney JJ, Fankushen DS, et al. Massive haemoptysis. Arch Int Med 1968; 121: 48598
9 Kato R, Sawafuji M, Kawamura M, Kikuchi K, Kobayashi K. Massive hemoptysis successfully treated by modified bronchoscopic ballon tamponade technique. Chest 1996; 109: 8423
10 Morell RC, Prielipp RC, Foreman AS, Monaco TJ, Royster RL. Intentional occlusion of the right upper lobe bronchial orifice to tamponade life-threatening hemoptysis. Anesthesiology 1995; 82: 152931[ISI][Medline]
11 Cicenia J, Shapira N, Jones M. Massive hemoptysis after coronary artery bypass grafting. Chest 1996; 109: 26770
12 Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28: 16427[ISI][Medline]
13 Dupree HJ, Lewejohann JC, Gleiss J, Muhl E, Bruch HP. Fiberoptic bronchoscopy of intubated patients with life-threatening hemoptysis. World J Surg 2001; 25: 1047[ISI][Medline]
14 Marshall TJ, Flower CDR, Jackson JA. The role of radiology in the investigation and management of patients with haemoptysis. Clin Radiol 1996; 51: 391400[ISI][Medline]
15 Plessinger VA, Jolly PN. Rasmussens aneurysms and fatal hemorrhage in pulmonary tuberculosis. Am Rev Tuberculosis 1949; 60: 589603[ISI]
16 Dalan JE, Haffajee CI, Alpert JS, et al. Pulmonary embolism, pulmonary hemorrhage and pulmonary infarction. N Engl J Med 1977; 296: 14315[Abstract]
17 Cosmo LY, Risi G, Nelson S, Subramanian P, Martin D, Haponik EF. Fatal hemoptysis in acute bacterial endocarditis. Am Rev Resp Dis 1988; 137: 12236[ISI][Medline]
18 Scarlat A, Bodner G, Liron M. Massive haemoptysis as the presenting symptom in mitral stenosis. Thorax 1986; 41: 4134[ISI][Medline]
19 Lhote F, Guillevin L. Polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome. Clinical aspects and treatment. Rheum Dis Clin North Am 1995; 21: 91147[ISI][Medline]
20 Shapiro MJ, Albelda SM, Mayock RL, McLean GK. Severe hemoptysis associated with pulmonary aspergilloma. Percutaneous intracavitary treatment. Chest 1988; 94: 122531[Abstract]
21 Foster DC, Stern JL, Buscema J, Rock JA, Woodruff JD. Pleural and parenchymal pulmonary endometriosis. Obstet Gynecol 1981; 58: 5526[ISI][Medline]
22 DeLima LGR, Wynands JE, Bourke ME, et al. Catheter-induced pulmonary artery false aneurysm and rupture: case report and review. J Cardiothorac Anesth 1994; 8: 705
23 Karmy-Jones R, Lee CA, Nicholls SC, Hoffer E. Management of aortobronchial fistula with an aortic stent-graft. Chest 1999; 116: 2557
24 Kawashima M, Katoh O, Aoki Y, Nakahara Y, Yamada H. A case of gauzeoma with recurrent massive hemoptysis mimicking aspergilloma. Nippon Kyobu Shikkan Gakkai Zasshi (Japan) 1994; 32: 1525[Medline]
25 Julia-Serda G, Freixinet J, Abad C, et al. Massive hemoptysis as a manifestation of fistulized thoracic aortic aneurysm into the bronchial tree. J Cardiovasc Surg 1996; 37: 4179[ISI][Medline]
26 Wu MH, Lai WW, Lin MY, Chou NS. Massive hemoptysis caused by a ruptured subclavian artery aneurysm. Chest 1993; 104: 6123[Abstract]
27 Remy J, Voisin C, Dupuis, et al. Traitement des hemoptysies par embolization de la circulation systemique. Ann Radiology (Paris) 1974; 17: 516
28 Feigelson HH, Ravin HA. Transverse myelitis following selective bronchial arteriography. Radiology 1965; 65: 6635
29 Di Chiro G. Unintentional spinal cord arteriography: a warning. Radiology 1974; 112: 2313[ISI][Medline]