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Haemoptysis - massive


- haemoptysis which ceases to be simply a sign of pulmonary disease and becomes a threat to life in its own right.
- volume of blood expectorated: 200-1000 ml/24 hrs depending on definition used


  • Infectious
    - TB
    - bronchiectasis
    - lung abscess
    - cystic fibrosis, bronchitis, aspergilloma
  • Malignant
    - bronchogenic CA
    - metastases
    - leukaemia
  • Cardiovascular
    - arteriobronchial fistula
    - CCF
    - pulmonary AV fistula
  • Diffuse parenchymal disease
  • Diffuse intrapulmonary haemorrhage (eg Goodpasture’s)
  • Trauma
  • Iatrogenic
    - pulmonary artery rupture
    - malposition of chest drain
    - tracheoarterial fistula

Management and investigation

  • admit to ICU or HDU
  • main objectives:
    • - prevent aspiration
      - localise site of bleeding
      - arrest haemorrhage
      - determine cause of haemorrhage
      - definitive treatment

  • CXR

- if site of bleeding can be lateralized nurse patient head down, lying on affected side to prevent aspiration of blood into healthy lung.
- avoid cough suppressants and sedatives and encourage patients to keep airways clear by gentle coughing
- transfuse blood as necessary
- correct hypoxaemia
- treat obvious causes of bleeding, eg clotting disorders, TB
- broad spectrum antibiotics IV - in patients with bronchitis or bronchiectasis bleeding may be precipitated by infection
- intubation and ventilation for patients with depressed level of consciousness or in imminent danger of asphyxiation. Double lumen tube to prevent soiling of other lung. Once patients condition is stable site and cause of bleeding should be sought.
- bronchoscopy -useful for localizing site of bleeding (which may be different from site suggested by CXR. Fibreoptic bronchoscopy is method of choice except in patients with massive uncontrolled haemorrhage in whom airway patency is moreeffectively maintained during bronchoscopy. Bronchoscopically placed endobronchial balloon may provide effective tamponade. Iced saline lavage and or endobronchial laser therapy may also be helpful.

Patients with persistent life threatening haemoptysis

- bronchial artery embolisation (should stop bleeding in the short term in almost all patients)
- emergency surgery should be reserved for those patients with adequate lung function in whom the site of haemorrhage has been identified who continue to suffer massive haemoptysis despite the above measures.

Tracheoarterial fistula

  • usually a complication of tracheostomy
  • if this is a possibility do not remove tracheostomy tube or deflate balloon
  • try overinflating the balloon and applying downward and forward pressure on top of tracheostomy tube in an attempt to tamponade bleeding at the site of the stoma. If the arterial rupture is at the tip of the cannula this will not help.
  • if bleeding stops or slows down an ETT tube should be placed beyond the tip of the tracheostomy tube and only then should the latter be removed, with an ENT surgeon standing by

Iatrogenic pulmonary artery rupture

  • complication of PA catheterization
  • attempt balloon tamponade of bleeding vessel. Deflate balloon, withdraw catheter 5 cm and inflate balloon with 5 cm air. Advance catheter again, allowing it to float into haemorrhaging vessel to occlude it.
  • angiography to localize arterial tear and to check for formation of pseudoaneurysm. Embolization if tear or pseudoaneurysm found

Further reading

Irwin RS, Curley FJ. Managing hemoptysis. In Rippe JM, Irwin RS, Fink MP, Cerra FB (eds), Intensive Care Medicine, 3rd ed. Little Brown & Co., Boston, 1996, pp 680-93

© Charles Gomersall December 1999


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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