Makindo Medical Notes

In the case of Massive Haemoptysis, protect the good lung at the expense of the bad lung. Death is typically due to asphyxiation and hypoxia rather than exsanguination if it is a unilateral process. As little as 250 mL of blood can fill the bronchial tree, making this condition life-threatening, though it is relatively uncommon.

About

• The most common causes include Aspergilloma, Tuberculosis (TB), Bronchiectasis, and endobronchial tumours.
• The lungs have a dual blood supply: the pulmonary and bronchial systems.
• Most haemoptysis originates from bronchial arterial supply, from aorta or intercostal arteries under systemic pressure.
• The pulmonary circulation can shunt blood away from hypoxic areas, providing some protective mechanism.

Causes

• Malignancy: Bronchogenic carcinoma, secondary lung tumours. Often seen in smokers aged over 40 years. Opacities may be seen on CXR.
• Infective: Pneumonia, lung abscess.
• Aspergilloma: Typically presents with cavitary lung disease seen on CXR.
• Bronchiectasis: Characterized by purulent sputum, recurrent haemoptysis, and cystic lesions at the lung bases on CXR. Common in cystic fibrosis.
• Tuberculosis: Common in individuals from Africa and Asia, those with HIV, and alcoholics. Often seen in younger patients (<40 years). CXR shows upper lobe opacities.
• Trauma: Can result from lung biopsy or bronchoscopy.
• Vasculitis: Granulomatosis with polyangiitis (Wegener's, cANCA positive), Goodpasture's syndrome (anti-GBM positive).
• Vascular: Pulmonary embolism (PE) with infarction. Typically presents with acute breathlessness, often disproportionate to CXR findings.
• Developmental: Pulmonary or bronchial arteriovenous malformations (AVMs).
• Bleeding Disorders: Includes thrombocytopenia, liver disease, haemophilia.
• Medications: Warfarin, heparin, or recent anticoagulation therapy.
• Other: Mitral stenosis, autoimmune conditions, or factitious haemoptysis.

Clinical

• Key history points include smoking, weight loss, clubbing, history of TB, or bleeding disorders.
• Consider underlying conditions such as cystic fibrosis or bronchiectasis.
• Massive haemoptysis is defined as >600 mL of blood expectorated in 24 hours.

Differential Diagnosis

• Verify that the bleeding is from the lungs (haemoptysis)
• Bleeding from nasopharynx (epistaxis)
• Bleeding from the gastrointestinal tract.

Investigations

• Blood Tests: FBC, U&E, clotting screen, arterial blood gas (ABG).
• CXR: Can help quickly identify the source of bleeding.
• CT Angiography: Best for identifying the bleeding source if the patient is stable enough.
• Bronchoscopy: Rigid bronchoscopy can help visualize and manage the bleeding source if it is not massive.
• Autoimmune Tests: cANCA (for Granulomatosis with polyangiitis), Anti-GBM antibodies (for Goodpasture's syndrome).

Management of Massive Haemoptysis

• The primary goal is to stop the bleeding. Immediate senior help is required. Involve interventional radiology and cardiothoracics. If a terminal event e.g. inoperable lung tumour then palliate
• ABC Approach: Provide high-flow oxygen, establish IV access, and prepare for emergency intervention. Lie the patient on the side of the bleeding lung to protect the good lung and facilitate aeration. The bleeding lung or the one that is source of bleeding if unilateral should be lowermost.
• Medications:
  • Nebulized Adrenaline (Epinephrine) 5-10 mL of 1 in 10,000 concentration can help control bleeding.
  • Nebulized Tranexamic Acid may be useful for minor bleeding or post-bronchoscopy bleeding
  • Oral or IV Tranexamic Acid can also be considered in more severe cases.
• Imaging:
  • Urgent Portable CXR may help identify the affected side and underlying pathology.
  • Ideally a CT with angiography of thorax is best if possible
• Airway Management:
  • If the patient is decompensating, consider intubation with a double-lumen tube or selective intubation of the non-bleeding main bronchus.
  • Endobronchial blockers can be placed during bronchoscopy to isolate the bleeding lung.
• Interventional Radiology:
  • Bronchial artery embolization (BAE) may be a definitive therapy in cases where the bleeding source has been identified.
  • Involves embolization of the bleeding bronchial artery under fluoroscopic guidance.
• Surgical Management:
  • Surgical resection or pneumonectomy may be indicated if BAE is unsuccessful or if the patient has a surgically treatable lesion.
  • Reserved for patients who are relatively healthy and have a localized bleeding source.
• Palliation: If the patient has terminal lung cancer or other non-treatable causes, consider palliative measures including diamorphine, morphine, or midazolam for symptom relief.