- Roadmap for management of severe hemoptysis
- Questions & discussion
General principles of hemoptysis
patients usually die from hypoxemia (not exsanguination)
- The primary concern is how the patient is doing from a respiratory standpoint (e.g. respiratory rate, saturation), not the patient's hemoglobin level.
- If the patient is coughing up lots of blood but keeping blood out of their lungs (normal oxygen saturation, no respiratory distress) – then they're doing OK. This looks scary, but in fact these patients are defending their lungs.
- If the patient is coughing up some blood but most of the blood is accumulating in the lungs (as revealed by hypoxemia & respiratory distress) – this is more immediately dangerous. Despite a lower volume of expectorated blood, these patients are at a higher risk of respiratory failure.
goals of therapy
- (1) Keep blood out of the lungs & preserve respiratory function. This may be achieved using the patient's own cough reflex (if they are keeping up with the bleeding). Alternatively, interventions such as an endobronchial blocker can be used (more on this below).
- (2) Stop the source of bleeding. This may involve manipulation of coagulation and direct intervention.
Ddx versus pseudohemoptysis
- Defined as expectoration of blood originating from the nasopharynx, oropharynx, larynx, or gastrointestinal tract.
- Important to recognize because it requires an entirely different diagnostic algorithm.
factors suggesting ENT source
- Subjective sensation of blood dripping downward in the posterior pharynx.
- Blood visualized in the nares.
- When in doubt consult ENT for nasolaryngoscopy – this test can be done rapidly and safely at the bedside. Occasional patients may be having severe posterior epistaxis masquerading as hemoptysis; this is essential to recognize rapidly.
factors suggesting GI source
- Coffee-ground appearance
- History of vomiting or regurgitation
Triage: who needs ICU?
definition of “massive hemoptysis”
- This is very vague, because in reality it's often impossible to precisely quantify the volume of hemoptysis.
- Numerous definitions exist, all of which are equally arbitrary and relatively unhelpful.
- A reasonable definition might be coughing up >200-600 ml fresh blood over several hours. This indicates the need for emergent therapy (26141487).
Definition of massive hemoptysis varies in the literature. Some say 150mL/24h, others say 600mL/24h I’ve always erred on the low end and prefer the term “life threatening hemoptysis”. Others say, “I know it when I see it”. This counts pic.twitter.com/YbLvWpvZbi
— David Feller-Kopman (@dfellerk) August 22, 2019
factors to consider in triage
- (1) Larger volumes of fresh red blood are more worrisome.
- (2) An acute-onset or an accelerating pattern is more worrisome.
- (3) CT may help: structural abnormalities (i.e. malignancy, bronchiectasis) & lots of blood in the lung tissue are worrisome.
- (4) Worsening respiratory failure is a worrisome sign (even if the patient isn't coughing up lots of blood).
- This implies accumulation of blood within the lung.
- (5) Underlying lung disease and degree of physiologic reserve.
Common causes of severe hemoptysis
- Lung cancer
- Metastatic cancer (e.g. renal cell CA metastatic to bronchi)
- Cystic Fibrosis
- Lung abscess
- Necrotizing pneumonia (bacterial or fungal)
- Aspergilloma (“fungus ball”)
- Septic pulmonary embolism due to right-sided endocarditis
- Mostly diffuse alveolar hemorrhage due to Granulomatosis with polyangiitis (previously known as Wegener's)
- tracheoinominate fistula
- PA catheter perforation
- transbronchial biopsy
There are numerous approaches to hemoptysis. This may depend to a certain extent on local resources and practice patterns. This roadmap is intended to provide a general schema for approaching this, but it certainly won't be applicable to every patient. For example, if the bleeding is clearly coming from a known central airway mass, then early involvement of interventional pulmonology would be warranted (and depending on the location of the mass, intubation might be impossible).
(0) Initial evaluation
history, focus on:
- ? Prior history of structural lung disease
- ? Tobacco history, history of malignancy
- ? Medications impairing coagulation
- ? Other infectious/inflammatory symptoms
- ? Recent procedures
- 1) Unilateral wheeze may reveal a focal endobronchial lesion.
- 2) Thoracic ultrasonography
- Focal B-lines may represent intra-parenchymal blood.
- Diffuse B-lines could raise a question of diffuse alveolar hemorrhage.
- CBC with differential
- Coags (INR, PTT, fibrinogen; thromboelastography in patients with cirrhosis)
- Urinalysis, ESR, and CRP if diffuse alveolar hemorrhage is possible.
stat portable chest X-ray
- Over time, blood may move around. This may eventually obscure what is going in.
- Even if a CT chest is ordered, consider getting a STAT chest x-ray. A film at an early time-point can be helpful.
- Chest X-ray may lateralize the bleed in ~46% of cases and identify a specific cause of bleeding in ~35%
nebulized tranexamic acid (TXA)
- Shown to be beneficial in one RCT which excluded patients with massive hemoptysis (30321510).
- Appears to be safe and well tolerated.
- This is a reasonable treatment to provide while awaiting other interventions or tests.
- Should not be viewed as definitive therapy.
- Should not delay or interfere with other interventions.
- More appropriate for patients on the more stable end of the hemoptysis spectrum.
- A reasonable dose might be 500 mg nebulized q8 hours (possibly with an initial dose of 1000 mg).
(1) Coagulopathy management
optimization of systemic coagulation
- Check coagulation tests and review medication list for any anticoagulants.
- Optimize coagulation as able (discussed further in chapter on anticoagulation reversal).
- Nebulized tranexamic acid may be considered (more on this below)
- Might help
- Shouldn't delay other interventions
- Shouldn't be considered definitive treatment for massive hemoptysis
(2) Is intubation beneficial?
intubation can cause harm
- Most patients are very good at coughing blood out of their airways. Intubation & suctioning is generally less effective than the patient's natural ability to clear their airway.
- If the patient is protecting their airway (e.g. blood is not accumulating in the lungs, there is no respiratory distress) – then intubation won't improve upon this. Intubation will likely impair clearance of blood from the airways.
- When able, it may be safest to avoid intubation (e.g. perform bronchoscopy and/or bronchial embolization under light sedation).
indications for intubation:
- (1) Ineffective cough (e.g. gurgling, inability to clear blood from airway).
- (2) Worsening respiratory failure (hypoxemia, dyspnea).
- (3) Intubation may be logistically necessary to facilitate CT scan and/or interventional radiology.
timing of intubation
- If intubation is required for respiratory failure (#1-2 above), then proceed without delay.
- If intubation is needed to expedite a procedure (#3 above) and patient is clearing blood effectively, then delay intubation as long as possible. For example, if the patient is effectively clearing blood from the airway and requires transport to another hospital, it might be safest to transport the patient without intubation first. In this scenario, intubation may actually destabilize the patient by impairing the natural cough reflex.
1/x I can't amen this first point enough!! If a person is coughing up blood and is holding their own physiologically, please don't take away the cough reflex with induction and intubation. Think about from physiologic perspective. What is deadspace of lung? ~150ml.
— Otis B Rickman, DO (@OtisBRickman) July 25, 2019
2/x How much deadspace is cleared with 1 cough? Almost all of it! How much can you clear with a 160cm bronchoscope with a 2.8mm working channel? Not that much!! Not to mention the amount of blood that will accumulate during apnea and cough suppression to facilitate intubation.
— Otis B Rickman, DO (@OtisBRickman) July 25, 2019
3/x Seen too many patients harmed by well-intentioned physicians who wanted to “secure” the airway during hemoptysis.
— Otis B Rickman, DO (@OtisBRickman) July 25, 2019
(3) CT is front-line investigation (not bronchoscopy)
CT has diagnostic yield superior to that of bronchoscopy in defining the bleeding lesion
- Similar efficacy vs. bronchoscopy with regards to localization.
- Superior efficacy in defining specific pathologic diagnosis (23932395). May identify site and cause of bleeding in ~75% of patients (31374211). This is far greater than bronchoscopy, which may identify a specific etiology of hemorrhage in closer to 50% of patients.
yield of CT scan may decrease over time
- Over time, lungs fill up with blood, which obscures the source of bleeding.
- Fluid instilled into the lungs during bronchoscopy (e.g. epinephrine or tranexamic acid) may mimic blood on CT scan.
immediate CT scan should be done if possible
- Contrast helps show vascular causes of bleeding (e.g. arteriovenous malformations).
- Detailed understanding of vascular anatomy may facilitate planning for IR embolization.
- A special CT protocol may help visualize both bronchial and pulmonary arteries. Discussion with radiology may ensure optimal CT technique.
(4) Bronchial artery embolization is often front-line treatment
Early & ongoing communication with interventional radiology is essential.
IR embolization is often the first-line therapy for severe hemoptysis (Khalil 2015).
- ~90% of massive hemoptysis originates from the bronchial arteries (under systemic pressure), rather than from the pulmonary arteries (a lower-pressure system). Overall, bronchial artery embolization has an initial success rate of ~80% (31374211).
- Usually embolization is directed at bronchial arteries, but it can also target pulmonary arteries.
- One potential exception is large central airway masses, which may be supplied by several vascular territories and thus be difficult to embolize.
- Interventional pulmonology may be more useful for these lesions.
- Success is improved by pre-procedure localization of bleeding (via bronchoscopy or CT).
- If the first embolization fails, repeat embolization may still be successful.
- Risk factors for recurrent bleeding after initial embolization include aspergillomas, tuberculosis, bronchiectasis, and non-bronchial systemic collateral circulation (31374211).
(5) Intubation procedure itself
- Blood may camouflage anatomic landmarks, making intubation difficult.
- Be prepared to suction, ideally with a large-bore suction catheter (LINK).
- Be prepared to proceed to cricothyrotomy if the airway fills with blood and all landmarks are obscured.
use a large ETT
- Ideally #9 ETT for patients who are average size or taller. Davidson et al. suggest using an 8.5 mm ETT or larger (31374211).
- Using a large-bore ETT will facilitate bronchoscopy and placement of an endobronchial blocker (if needed).
Listened to the awesome @iBookCC podcast this morning.
— Matt Siuba (@msiuba) July 25, 2019
do not place a double-lumen ETT!
- A double-lumen ETT (with one lumen in each bronchus) sounds neat, but in practice works poorly for the following reasons.
- (a) Placement is tricky.
- (b) The tube is easily malpositioned (not a very stable airway).
- (c) It's difficult to perform bronchoscopy through the small lumens.
- (d) To control massive hemoptysis, a double-lumen ETT requires shutting down an entire lung. In contrast, an endobronchial blocker can be placed within a lobar or segmental bronchus (thereby shutting down less lung tissue).
potential goals of bronchoscopy
- May define a focal source of bleeding (e.g. endobronchial tumor or blood coming from a single airway).
- Note, however, that it is often difficult to tell where the blood is coming from. There is real potential for operator error/misdiagnosis. CT is replacing bronchoscopy as the first-line test to localize bleeding (26141487).
- May diagnose diffuse alveolar hemorrhage (blood coming from all airways, doesn't clear with sequential lavage).
- Occasionally used to deploy an endobronchial blocker to contain the bleeding.
who needs bronchoscopy?
- Not every patient with hemoptysis. If CT scan shows a culprit lesion, bronchoscopy may not be needed.
- Potential indications
- Generally done in anyone intubated due to hemoptysis (to assess the severity of bleeding and perform tamponade if necessary)
- If source of bleeding remains unclear despite CT scan.
instillation of tranexamic acid through the bronchoscope
- Traditional approach was to instill cold saline, epinephrine, or activated factor VIIa. None of these are particularly attractive (activated factor VIIa may work, but it is profoundly expensive).
- The best option may be endobronchial tranexamic acid. There isn't a lot of evidence supporting this, but it seems to work (23966576). The largest reported study used a regimen of 500 mg diluted in 15 ml saline (23168726).
(6a) Non-intubated bronchoscopy (“awake bronch”)
- Try not to sedate the patient too much (so that their cough reflex remains preserved and they are able to clear blood from their lungs after the procedure).
- Main goal is to identify a focal source of bleeding (if present) or to determine whether the patient might have diffuse alveolar hemorrhage.
(6b) Intubated bronchoscopy
- Deep sedation (e.g. high-dose propofol infusion) will make this easier, because the patient won't cough and shift blood around. A static lung will make it easier to determine where blood is coming from.
- If focal bleeding is found, an endobronchial blocker can be placed to tamponade bleeding (while preserving function of the remaining lung).
- If bleeding localized to specific lung/lobe/segment, this may be blocked off with balloon tamponade.
- The goal is to compartmentalize bleeding & protect the remaining lung tissue.
- Video below shows how this is done.
- Either paralysis or deep sedation (e.g. propofol infusion) is generally needed to prevent the patient from coughing this out or dislodging it.
(7) Interventional pulmonology
- There is increasing use of advanced bronchoscopic techniques to achieve hemostasis (e.g. argon plasma coagulation, rigid bronchoscopy).
- This is primarily useful for lesions in the proximal airways. As such, the utility of interventional pulmonology may be gauged, based on CT scan and/or flexible bronchoscopy showing a large airway lesion.
(8) Surgical resection
a surgical approach requires the following:
- (a) Localized bleed that is refractory to other therapies
- (b) Patient with sufficient pulmonary function to tolerate resection of the involved lung tissue (e.g. pneumonectomy or lobectomy).
- Patients with hemoptysis cannot undergo pulmonary function tests, so their ability to tolerate resection must be estimated based on their pre-morbid functional capacity (e.g. how many flights of stairs are they able to climb).
utility of surgery?
- Not generally an option for patients with massive hemoptysis and underlying lung disease (e.g. COPD, bronchiectasis, lung cancer).
- Surgery works best for a previously healthy patient with a specific focus of bleeding (e.g. broncholith, aspergilloma, lung abscess, bronchial adenoma).
(9) Diffuse alveolar hemorrhage
This requires an entire chapter – see diffuse alveolar hemorrhage chapter (sorry we will get there eventually).
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Questions & discussion
To keep this page small and fast, questions & discussion about this post can be found on another page here.
- Rushing every patient to bronchoscopy (since bronchoscopy has a lower yield than CT scan). Whenever possible, early multi-detector CT angiography of the chest can be enormously helpful.
- Failure to correct coagulopathy.
- Intubation is often counterproductive: it doesn't fix the problem, and may actually increase blood accumulation in the lung. Intubation should ideally be avoided or delayed if possible.
- Placement of an ETT that doesn't allow for bronchoscopy (small ETT, or double-lumen ETT).