Haemoptysis

Introduction

• Massive/severe
  • Variable definition
  • >100mL per 24 hours to >1000mL per 24 hours
  • 600mL per 24 hours accepted by many
  • >600mL in <4 hours has mortality 71%
• Minor haemoptysis
  • Small-volume expectoration of blood in a patient with no underlying lung disease, normal oxygenation/ventilation, normal vital signs and no risk factors for continued bleeding

• Usually asphyxiate to death rather than bleed to death

Pathophysiology

• Pulmonary arteries responsible for 99% of blood flow to lungs, but are a low pressure system and rarely the source of bleeding
• Bronchial circulation constitutes 1% of blood flow but 90% of bleeding episodes as it is a high-pressure system
  • Responsible for delivery of oxygenated blood to bronchi, pulmonary arteries and veins, and lung parenchyma
  • Follow tortuous route of bronchi
  • Once reach capillaries, three anastomoses occur:
    • Large bronchial arteries merge with alveolar microvasculature
    • Smaller bronchial arteries merge with veins of pleural and pulmonary drainage system
    • Bronchial capillaries merge directly with pulmonary capillaries
  • These anastomoses produce physiological right to left shunt comprising 5% of total cardiac output

• Alveolar haemorrhage rarely causes massive haemoptysis

Causes

• TILDA acronym
• Tracheobronchial disorders
  • Tracheobronchitis, aspiration, adenoma, carcinoma, telangiectasia, bronchiectasis, foreign body, fistula, trauma
• Iatrogenic
  • Intubation, bronchoscopy, biopsy, suctions catheters, Swan-Gannz
• Localised parenchymal disease
  • Pneumonia, PE, tropical (amoebiasis, ascariasis, aspergilloma, coccidiomycosis, histoplasmosis), metastatic cancer, nocardiosis, lung abscess
• Diffuse parenchymal disease
  • Viral pneumonitis, scleroderma, Goodpasture’s, Wegener’s, SLE
• Anticoagulants
  • Drugs, DIC, leukaemia, thrombocytopaenia
• + Cardiac disease
• Coughing in transient airway inflammation e.g. acute bronchitis
• Chronic inflammatory states (COAD, TB, CF) result in neoangiogenesis with thin-walled, fragile vessels
• Chronic bronchiectasis leads to loss of cartilagenous support, predisposing to vessel rupture
• Aspergillus cavitary fungal balls with neoangiogenesis within cavity walls
• PE with infarction
• Rasmussen’s aneurysm
• False aneurysm of dilated, tortuous branches of pulmonary arteries crossing the wall of a tuberculous cavity)
• Tumours can invade vessel walls and lead to neoangiogenesis (SCC especially)
• Traumatic deceleration injuries or penetrating injuries
• Iatrogenic during procedures
• Biopsy of a carcinoid tumour especially
• Fistulae
  • Between aorta and its primary branches 
  • Tracheo-innominate fistulae result from erosion of a tracheostomy into the innominate artery coursing posterior to the sternum
• Cardiac disease that leads to raised PAP (e.g. mitral stenosis; congenital HD, left-sided endocarditis)
• Vasculitis
• Goodpasture’s, SLE, Wegener’s granulomatosis damage the lung parenchyma leading to alveolar haemorrhage
• Catamenial (pulmonary endometriosis)
• Cause in 30% undetermined

Clinical features

• Identify if truly haemoptysis (exclude haematemesis and epistaxis)
• Expectorated blood is bright coloured if the source is upper airways or lungs
• History
  • Smoking, TB, VTE, haematuria/renal disease, arthalgias/myalgias/rash/fevers, cyclical bleeding (catamenial), anticoagulants
• Examination
  • Sputum – blood-streaked or clots
  • Signs of major bleeding
  • Nares and posterior pharynx for epistaxis
  • Airway patency and intubation assessment
  • Auscultation – Focal site of bleeding or wheeze suggesting chronic inflammation
  • Crackles may suggest diffuse alveolar haemorrhage or CCF
  • Murmurs of valve disease
  • Telangiectasia, petechiae, rash

Diagnosis

• FBC, Chem20, Coags, urinalysis
  • Thrombocytopaenia and coagulopathy increase risk of recurrence
  • Urinalysis and renal fx test help rule out Goodpasture’s and Wegener’s
• ECG
• Consider echo
• Imaging
  • CXR yields diagnosis in 50%
    • In massive haemoptysis, X-ray is rarely normal
    • Diffuse alveolar haemorrhage
      • Scattered alveolar infiltrates
    • Focal lesions suggest source
  • CT angiography
    • Delineates abnormal bronchial and non-bronchial arteries
    • Can detect bleeding from Rasmussen’s aneurysm or anomalous vessel
    • Bronchial arterial bleeding almost always identified
    • Non-bronchial arterial sources identified >50% of the time
    • Limitation is that areas of bleeding can appear similar to infiltrate/tumour and active bleeding can obscure a mass

Treatment

• Mild haemoptysis
  • Normal CXR
    • Under 40, non-smoker, <2 weeks, single episode = GP follow-up
      • Treat for LRTI if suspicious
    • Over 40, smoker, >2 weeks, recurrent = Chest CT, thoracic medicine consult
  • Mass lesion
    • Labs, urinalysis and resp consult
    • Consider CT chest for staging
    • Bronchoscopy
  • Other parenchymal disease
    • Labs, urinalysis and resp consult
    • High-resolution CT +- bronchoscopy if no specific diagnosis suggested
• Massive haemoptysis
  • Bronchial artery embolization
    • Most effective non-surgical first-line treatment
    • 80% successful
    • Recurrence rate 30%
  • Bronchoscopy
    • Adrenaline
    • Balloon tamponade
    • Need airway control, rate of bleeding amenable to visualization and haemodynamic stability
  • Surgery
    • Last-line of defence
• Airway control
  • If tracheostomy – check for tracho-innominate fistula and apply direct pressure using Utley maneuvre
  • If requiring intubation, use largest ET possible and RSI
  • If bleeding from both lungs, head down
  • Place affected lung in dependent position if possible once intubated to prevent spillage into unaffected lung
    • However, may worsen VQ mismatch
  • If bleeding uncontrollable, may intubate main bronchus of unaffected lung only
  • Some advocate using a Foley catheter (14F/100cm) to block affected lung after intubation
  • Treat as per massive transfusion
• Bronchoscopy
  • Awake, flexible fibreoptic bronchoscopy
    • Allows visualisation of more peripheral and upper lobes but does not provide optimal suctioning  or local treatment
  • Rigid bronchoscopy requires GA or deep sedation
    • Cannot fully view upper lobes or peripheral lesions but offers better suctioning and treatment e.g. Fogarty balloon catheters for tamponade, adrenaline instillation and ice water lavage
    • Can perform flexible bronchoscopy through lumen of rigid bronchoscope after control achieved
• Definitive bleeding control
  • Emergency OT
    • Leaking aortic aneurysm, iatrogenic pulmonary artery injury, thoracic trauma or tracheo-innominate fistula
  • Otherwise, IR bronchial artery embolisation generally preferred for massive/recurrent haemoptysis
    • Risks include transverse myelitis due to spinal cord ischaemia and pulmonary artery infarction from spread of embolic material beyond intended site

Last Updated on October 28, 2020 by Andrew Crofton