D. P. Laporta MDD. P. Laporta MD

Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital

McGill University

presented to McGill Residentspresented to McGill ResidentsCritical Care (January 2000)Pulmonary (July July 2000

MASSIVE HEMOPTYSIS

REFERENCES

•Bone: Pulmonary & Critical Care Medicine, 1998 ed., 1998 Mosby-Year Book, Inc.Ch R19 Massive HemoptysisCh M10 Pulmonary Hemorrhage Syndromes

•Jean Baptiste E «clinical Assessment and management of massive hemoptysis Crit Care Med 2000; 28:1642-7

•Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis, in : Flexible bronchoscopy in the 21st century. Clin. Chest Med. 1999; 20(1) March

•White R. Jr. Bronchial Artery Embolotherapy for Control of Acute Hemoptysis. Analysis of Outcome . Chest 1999; 115(4) April

•Fanburg BL et al, Case 52-1993: A 17-Year-Old Girl with Massive Hemoptysis and Acute Oliguric Renal Failure. NEJM Weekly CPC. 1993; 329(27)

MASSIVE HEMOPTYSIS

Definition

Natural History

InvestigationsCXRFOBCTOthers: echo , V/Q, Duplex, Pulm Angio,Bloodwork

InterventionsMedical: conservative, BAESurgical

HEMOPTYSIS

USUAL HEMOPTYSIS Frequent Life Frightening

1% to 14% of all patients with hemoptysis

MASSIVE HEMOPTYSIS Rare ( 1-14 % of pts with H) Life Threatening

one of the most frightening of medical emergencies …for patient and physician !!!

CHALLENGE: explosive clinical presentation

MAJOR RISK: impending asphyxiation

need to respond quickly and appropriately

MASSIVE HEMOPTYSIS

NATURAL HISTORY AND PROGNOSIS

MORTALITY

Immediate : 7% of 113 patients who presented with massive hemoptysis died soon after onset.

Etiology : TB 18.6%, CF 32%, Other 10% DURATION

If survive the initial episode, bleeding stops <3-6 days

RECURRENCE RATE

20-46% after bronchial embolization

MASSIVE HEMOPTYSIS

Prognostic Features Associated with Death • bleeding exceeding 1000 mL/24 h

600 mL of hemoptysis in <4 hours 71%mortality4-16 hous 22% 16-48 hours 5%

• hemodynamic instability• CXR evidence of aspiration • bilateral bleeding sources• inability to localize source of bleeding

• caused by a neoplasm• inadequate pulmonary function• debilitated states, and metastatic cancer

• MORTALITY 80 % if > 1L/24 h PLUS malignancy

MASSIVE HEMOPTYSIS

DEFINITIONS

> 100 mL/24 hrs

> 200 mL/24 hrs

> 300 mL/24 hrs

600 mL/24 hrs

> 1000 mL/24 hrs

OverestimateOverestimate

UnderestimateUnderestimate

400 ml = abN gas XC

Hemoptysis: is it real ?

GIFactitious (Munchausen ’s)Pseudo: drugs (RFP, clofazimine)Serratia pneumoniaENT

MASSIVE HEMOPTYSIS

SOURCES OF HEMOPTYSIS

2 interconnected circulations :

pulmonary (low pressure)

bronchial (systemic pressure)- proximal airways (trachea and

main stem bronchi) …RA

- peripheral airways/parenchyma…bronchopulmonaryanastomoses (r-l shunt)…pulmonary veins…LA

Bronchial Circulation

Come directly or indirectly from the aorta (T3-8)

VariabilityVariability

NonbronchialNonbronchial systemic collateral arteries

in 45% of patients with hemoptysis

commonly: intercostal, subclavian, axillary & phrenics

uncommonly: IMA, thyrocervical, carotid, coronaries

Because of the many systemic arteries involved, routine arteriographic localization cannot be all-inclusive

MASSIVE HEMOPTYSIS ETIOLOGY (1)

Infectious (bacterial, mycobacterial, viral, fungal, parasitic)

Lung abscess

Bronchiectasis (including cystic fibrosis)

Mycetoma (e.g., aspergilloma)

Infected BP Sequestration

Septic emboli

Infected aortic graft

NeoplasmMalignant Bronchogenic

Metastasis from pulmonary/extrapulmonary

Benign (bronchial adenoma)

MASSIVE HEMOPTYSIS ETIOLOGY (2)

Foreign body/traumaAspirated foreign bodyBroncholithTracheovascular fistulaTrauma, Brachytherapy, Laser

Cardiac/pulmonary vascularPulmonary venous HTN

Mitral stenosis, PVOD

(Pulmonary embolus)Pulmonary artery

Perforation (complicating Swan-Ganz catheter)Aneurysm/false (mycotic, Behcet’s, Hughes-Stovin)

Arteriovenous malformations

OWR, DieuLaFoye

Fistulae (every vessel parring through the thorax)

MASSIVE HEMOPTYSIS ETIOLOGY (3)

Alveolar hemorrhage

Goodpasture's syndrome

Systemic vasculitides/collagen vascular diseases…capillaritisBehcet's syndromeEssential mixed cryoglobulinemia, Henoch-Schonlein purpuraProgressive systemic sclerosisRheumatoid arthritis, Systemic lupus erythematosus, Mixed connective tissue disease Systemic necrotizing vasculitis, Wegener's granulomatosis

Other Glomerulonephritis

Immune complex associated glomerulonephritisPauci-immune glomerulonephritis

Familial

Acute Leukemias

MASSIVE HEMOPTYSIS ETIOLOGY (4)

Drug-induced

Cocaine, D-penicillamine, Isocyanates, Nitrofurantoin, Trimellitic anhydride

Anticoags, Thrombolytics, ASA

MASSIVE HEMOPTYSIS ETIOLOGY (4)

Miscellaneous• Idiopathic hemosiderosis • Coagulation disorders

Thrombotic thrombocytopenic purpuraDIC

Acquired coagulopathy (permissive)• Endometriosis (Catamenial hemoptysis)• Sarcoidosis • Lymphangioleiomyomatosis

• Chronic Lung Disease– Emphysematous bullae

– Pneumoconiosis

MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS BEDSIDE ASSESSMENT BEDSIDE ASSESSMENT

OF THE PATIENTOF THE PATIENT

• Clubbing, Simian crease, Cutaneous nodules/pustules + uveitis

• IVDU with septic thrombophlebitis, palpable purpura, malar rash

• Oral: ulcers, mucosal telangiectasias,

• Post-URI rhinitis, saddle nose

• Stridor/wheezing

MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History

Young adult female ...Young adult female ...

• otherwise healthy• with recurrent CHF & A fib

• with spontaneous pneumothorax + ILD

• menstruating

MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History

Inflammatory Lung DiseasesInflammatory Lung Diseases

• bronchiectasis

• abscess

• necrotizing pneumonia

• infected cavity/bulla (mycetoma)

MASSIVEMASSIVE HEMOPTYSISHEMOPTYSIS Clinical History

TUBERCULOSISmore common in the presence of cavitary

disease.

pathologic lesions Rasmussen's aneurysms bronchial artery erosions from tb airway

inflammation or bronchiectasis; secondary infections of prior tuberculous

cavities (eg Aspergillus)

Specific clinical situations Specific clinical situations

presenting with presenting with

MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS

TracheostomyPost-Partum

Southeast Asia, Middle East South AmericaLymphoma

Acute LeukemiaCardiac Surgery

High-power magnification showing capillaritis,

which is characterized by infiltration of the alveolar septae

by neutrophils (arrow). Note the presence of scattered red cells

in the parenchyma (H&E stain, original magnification × 400).

DIFFUSE ALVEOLAR HEMORRHAGE

Bloody BAL fluidhemosiderin-laden macrophageslack of infectious pathogens

...are sufficient to establish DAH.

Causes of MH Associated With aCauses of MH Associated With a Normal Chest Radiograph Normal Chest Radiograph

BronchiectasisPulmonary embolismLung carcinoma in the trachea or large airwaysPulmonary artery dissection or rupture

MANAGEMENT of MHMANAGEMENT of MH

1. Make the right etiological DIAGNOSIS ! Hx. Px, Sputum, Bloods, FOB, Imaging

2. Determine the SITE of bleeding Hx, Px, CXR (?CT) FOB : flexible, rigid

• observe mucosa etc., washings: culture incl TB, cytology

3. Airway control/pt stabilizationsurgical candidate ?

4. Specific Therapy

STEP SPECIFICRECOMMENDATIONS/OPTIONS

COMMENTS/RATIONALE

(1) PROTECT AIRWAY AND STABILIZE PATIENT

Admit and monitor Intensive care unit Allows close monitoring ofhemodynamics and magnitude ofblood loss

Maintain adequateairway

Size 8 endotracheal tube To facilitatesuctioning/bronchoscopy

Consider double lumen tube

Consider unilateral intubation Bronchoscopy can help verifyplacement

Supplementaloxygen

Correctcoagulopathy

Blood, fresh frozen plasma

Fluid resuscitationConsider intravenous vasopressin

Stool softenersPrevent straining

Cough suppressants

Lateralize bleeding Bleeding lung down

If bleeding lateralized rather than localized:

A right-sided bleeding : B left-sided bleedingL lung selectively intubated trachea intubated over bronchoscope firstOver the bronchoscope. with the patient in the left lateral position to

minimize aspiration14Fr 100 cm Fogarty catheter passed through thevocal cords beside the endotracheal tube to a levelseveral centimeters below the cuff.

DOUBLE LUMEN ETT FOR ENDOBRONCHIAL TAMPONADE.

bronchial lumen: placed in L main bronchus to ventilate L lung

tracheal lumen: remains supracarinal to ventilate R lungand prevents occlusion of the RUL orifice.

external lumina connected to ventilator using a "Y" connector device.

Left and right-sided double lumen tubes are currently available.

DOUBLE-LUMEN ETT IN DOUBLE-LUMEN ETT IN MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS

Requires expertSmall lumina : difficult insertion, easy obstruction

62 patients with MH• 4/7 pts with DL-ETT : aspiration and death

• cause : loss of tube position and pulmonary aspiration during surgery.

• L bronchial ETI : 0/12 deaths from

• L Fogarty- Tracheal ETI : aspiration

(2) LOCALIZE THESOURCE OF BLEEDING

Hx, Px

Radiology CXR

Bronchoscopy Flexible

Rigid

Early bronchoscopy helpsidentify exact location andguide further management

LIMITATIONS: Upper lobes Peripheral disease

TIMINGTIMINGOF BRONCHOSCOPYOF BRONCHOSCOPY

The The sicker,sicker, the the earlierearlier ! !

site of bleeding visualized more commonly with early bronchoscopy (within 48 hours)

unlikely relevant in non-massive hemoptysis

(3) ADMINISTER SPECIFIC THERAPY

Bronchoscopictherapies

Iced saline lavage

Topical agents Epinephrine, thrombin, thrombin-fibrinogen

Endobronchialtamponade

Size 4 to 7 French catheter, J-wire(through nostril), bronchus blocker

Laserphotocoagulation

For endobronchial lesions

Pharmacologic Rxs Vasopressin

Tranexamic acid

Systemic steroids In cases of alveolar hemorrhage

GnRH/danazol In catamenial hemoptysis

Antibiotics/anti-TB/anti-fungals

In cases of suspected or known infection

Angiography andembolization

Standard/superselective

Semidefinitive therapy, or bridge tosurgery

Radiation therapy In aspergillomas and vascular tumors

Surgical resection(ifpulmonary functionallows)

CavernostomySegmentectomyLobectomy2Pneumonectomy

If embolization not feasible (unavailable,technically impossible, or did not stopbleeding), patient too unstable to wait forangiogram, or cause of hemoptysis notlikely to benefit from embolization (PAperforation, ruptured mycetoma)

Role of bronchoscopy is presented in bold typeface.

Management of MHManagement of MH

BRONCHIAL ARTERY EMBOLIZATION (1)BRONCHIAL ARTERY EMBOLIZATION (1)

successful immediate control 64% to100%. Technical inability to cannulate : 13% Recurrence of bleeding

• Immediate 20-40%

• Follow-up post BAE 1 year: 16 % 3 years : 23% Complications :

• vessel perforation/intimal tears

• sequelae of bronchial artery occlusion (e.g., chest pain, fever, hemoptysis)

• inadvertent ectopic emboli.

• mesenteric occlusion

• vessels supplying the extremities

• ASA embolization reduced withcoaxial microcatheter system :"superselective" ba

catheterization/bae without occluding other branches

Management of MHManagement of MH

BRONCHIAL ARTERY EMBOLIZATION (2)BRONCHIAL ARTERY EMBOLIZATION (2)

most difficult : identify the vessel(s) responsible for bleeding.

injection in the descending aorta just below the left subclavian artery

may require a full-arch aortogram in some LL bleeding w/no apparent bronchial supply: UL bleeding: unilateral subclavian artery injection

to exclude nonbronchial systemic collateral arteries.

formal bronchial arteriogram blush,abnormal vessels, ensures that no

communication to the anterior spinal artery

Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?

Observational studies no RCTs… selection bias none used bae as part of medical therapy wide range of mortality rates :

• surgical (1-50%) and medical (1.6-85%) results are mixed …lower surgical

mortality rates

Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?Current recommendationsCurrent recommendations  : surgical resection preferred if:

BAE unavailable or failed imminent survival threatened by transport to radiology (ABCs) surgically operable patient with a localized (ie resectable) lesion as

cause of MH which is deemed unlikely to be controlled by BAE:

– Thoracic vascular injury/trauma

– mycetoma +profuse collateral arterial supply,

– hydatid cyst

– bronchial adenoma

– AVM

PA RUPTURE PA RUPTURE (1) Epidemiology Prevalence .06-.2% Rebleed: 90 % within 3 days Mechanism:

Pseudoaneurysm (Psan) Mortality:

all comers 45-65%

if rebleed: 40-70%

26% if abnormal CXR is only manifest'n of PA rupture

65% if clinical hemorrhage (ie hemoptysis, hemothorax, parenchymal bleed - HHPB)

CXR may be normal despite PA rupture ? Psan

PA RUPTURE PA RUPTURE (2)

Contributory causes technical errors (improper equipment, technique or

judgment) age > 60PA hypertensionanticoagulatedhypothermia inhalational anesthetic agentsperi-CPB (especially intraop)

SUSPECTED PA RUPTUREHEMORRHAGE (HHPB) OR

NEW PULMONARY INFILTRATE RIGHT AFTER PAC INSERTION

pull back PAC !

EmergencyResuscitation-Management:ABC !

HEMOPTYSISBronchoscopeDouble-lumen ETTEndobronchial ETT

HEMOTHORAX

CONSIDERlung resection

If PatientSurvives

Infused CT

Dx pseudoaneurysm

CONSIDERtherapeutic angiolung resection

IN OR

HEMOPTYSIS

(see column 1)

if massive: resume CPBbefore maneuvers

CONSIDERlung resection