Day #94 - Hemoptysis

The discussant today gave an excellent approach to hemoptysis, which has a broad differential. We highlighted the importance of distinguising hemoptysis from hematemesis and epistaxis. I wanted to discuss "massive" hemoptysis in more detail.

Severe/Massive hemoptysis can be defined as blood volume >100-600cc and may be associated with hemodynamic instability and respiratory comprimise. Massive hemoptysis makes up ~5% of all hemoptysis and has a mortality quoted as up to 80%.

There are many potential causes. The most common in case series are:

• Bronchiectasis
• Tuberculosis
• Bronchogenic carcinoma
• Pneumonia
• Aspergilloma
• "Bronchitis"
• Coagulopathy
• Other -- Includes pulmonary renal syndrome, diffuse alveolar hemmorhage

Key issues in management:

1. Protect the airway. Includes positioning the patient with bleeding lung down, intubating patient with selective bronical intubation of "good lung" if possible and blockage of the "bad lung"
   
   • In cases related to the left lung, you may, at the bedside be able to advance the ETT into the right mainstem bronchus once the patient is intubated because of the anatomy
2. Supportive measures:
   
   • IV access, fluids, pressors, blood
   • Fix coagulopathies
3. Investigate/Treat:
   
   • Fiberoptic bronchscopy to visualize. If inadequate, rigid bronchoscopy. Certain therapies can be performed with the rigid bronch
     
   • If continues to bleed, and/or source can't be found angiography, usually bronical artery to localize and embolize bleeding source
   • High res CT scan if patient stable enough to move there and diagnostic uncertainty.