1 What is hemoptysis?

Hemoptysis is the expectoration of blood originating from the lower respiratory tract. It is classified on the basis of the volume of expectorated blood.

2 How are hemoptysis and pseudohemoptysis different?

Pseudohemoptysis is expectoration of blood originating from a source other than the lower respiratory tract. It results from either aspiration of blood from the gastrointestinal tract or blood draining into the larynx and trachea from bleeding sites in the oral cavity, nasopharynx, or larynx.

3 Describe the differential diagnosis of hemoptysis

The differential diagnosis of hemoptysis is based on the site of bleeding. Hemoptysis in general results from either a focal or a diffuse tracheobronchial (airway) or pulmonary parenchymal process (Box 25-1). Occasionally nonpulmonary processes, in particular cardiac, vascular, or hematologic disorders, may result in bleeding in the lungs. The frequency with which hemoptysis is associated with these conditions is determined by the age of the patient, the population being studied (e.g., surgical vs. medical, veterans hospital vs. city or county indigent hospital), and the amount of expectorated blood. Approximately 30% of cases are cryptogenic, and no explanation for hemoptysis is determined despite extensive evaluation.

4 What are the common causes of massive hemoptysis?

The most common causes of massive hemoptysis are bronchiectasis, active or inactive tuberculosis, necrotizing pneumonia (including lung abscess) and fungal infections. The latter include both mycetoma (aspergilloma) and, less commonly, chronic necrotizing pulmonary aspergillosis. The relative frequency of these causes has changed in the past few decades and depends on both the institution and country from which the data are reported. Pulmonary neoplasm, arteriovenous malformation, pulmonary vasculitis, valvular heart disease (especially mitral stenosis), and bleeding diathesis are also potential causes of massive hemoptysis but occur less frequently.

5 Name the common iatrogenic causes of hemoptysis that occur in critically ill patients

When hemoptysis begins after endotracheal intubation, upper airway trauma caused by the intubation procedure, endotracheal tube, or endotracheal suction catheters must be considered. If hemoptysis begins after a latent period of 1 or more weeks after intubation, a tracheoartery fistula may be the source of hemorrhage. This possibility is increased if a tracheostomy tube is present. Pulmonary artery rupture and pulmonary infarction should be considered when hemoptysis occurs in a patient with a pulmonary artery catheter. Pulmonary infarction should be suspected if a wedge-shaped infiltrate is present distal to the catheter on the chest roentgenogram.

6 Explain the significance of massive hemoptysis

Massive hemoptysis is generally due to hemorrhaging from the bronchial artery (systemic pressure) circulation as opposed to the low-pressure pulmonary artery circuit and therefore is more capable of generating high-volume, life-threatening hemorrhage. Mortality from untreated massive hemoptysis in some studies is 75% to 100%.

7 List the tests that should be included in a routine evaluation of patients with hemoptysis

History, physical examination, complete blood cell counts including platelet count, coagulation studies, urinalysis, oxygenation by either pulse oximetry or arterial blood gas analysis, chest roentgenogram, and electrocardiogram.

8 What is the initial approach to the evaluation of a patient with hemoptysis in the intensive care unit?

Evaluation should begin with the routine tests previously described. After the patient has been hemodynamically stabilized, the site, etiology, and extent of bleeding should be determined. Identifying the site of bleeding requires visualization of the airways of both the upper and lower respiratory tract and examination of the chest roentgenogram. Pernasal fiberoptic bronchoscopy allows examination of the nasopharynx, larynx, and major airways and may reveal whether hemorrhaging is focal or diffuse. The presence of an endotracheal tube may compromise this examination. In this instance, upper airway bleeding may be detected by aspirating the trachea free of blood with a bronchoscope while the endotracheal cuff is expanded and then observing fresh blood flow down from above the cuff when it is decompressed. Rigid bronchoscopy may be required if hemorrhaging is massive, such that blood cannot be adequately removed with a flexible bronchoscope.

9 How does the chest roentgenogram assist in the evaluation of hemoptysis?

Examination of the chest roentgenogram often gives clues to both the site and etiology of hemoptysis. The presence of an infiltrate suggests the existence of a pulmonary parenchymal process. However, occasionally an infiltrate may occur after aspiration of blood coming from an airway source. Similarly, the presence of diffuse infiltrates suggests diffuse parenchymal disease, although this roentgenographic pattern may also occur with localized bleeding associated with severe coughing, which disperses blood throughout the lungs.

10 Do all patients with hemoptysis require bronchoscopy?

No. Bronchoscopy may not be indicated if the initial evaluation strongly suggests that hemoptysis is due to a cardiovascular etiology, a lower respiratory tract infection, or a single episode of frank hemoptysis caused by acute or chronic bronchitis. However, bronchoscopy should be reconsidered in these clinical settings if the patient’s hemoptysis does not improve or resolve after 24 hours of empiric therapy. Bronchoscopy is not indicated to make the specific diagnosis of a tracheoartery fistula.

11 Describe the immediate management of massive hemoptysis

The goals of immediate management of patients with massive hemoptysis are as follows:

Maintenance of airway patency is of paramount importance because death from massive hemoptysis more commonly results from asphyxiation due to major airway obstruction than from exsanguination. Several approaches have been advocated to maintain airway patency. If hemorrhage is occurring from a focal site and the site of hemorrhage is known, the patient should be positioned with the bleeding side dependent to prevent contamination of noninvolved airways. If the site of hemorrhage is unknown or diffuse, the patient should be placed in the Trendelenburg position. Other approaches to protect uninvolved airways include bronchoscopically guided selective intubation of the nonbleeding main stem bronchus or placement of a double-lumen endotracheal tube. The utility of double-lumen tubes is limited by the need for specialized training in their insertion and the tendency for double-lumen tubes to become dislodged.

12 What specific therapies may be useful to stop ongoing hemorrhage?

If the etiology of hemorrhage is known, specific therapy directed at the cause (such as antibiotics for bronchiectasis or corticosteroids for pulmonary vasculitis) should be instituted to stop ongoing hemorrhage. Coagulopathies should be corrected with administration of appropriate blood products. If the patient is receiving anticoagulant therapy it should be discontinued.

Life-threatening hemorrhage from a focal site requires more aggressive strategy. The most common of these is bronchial artery embolization (see question 14). Surgical resection may be considered in patients with adequate underlying lung function; however, because of the higher mortality associated with this approach when used emergently and the safety and efficacy of bronchial artery embolization it is usually reserved for those patients who have persistent bleeding despite other interventions. A number of bronchoscopic techniques are also available to control bleeding. These include the following:

13 Describe the management of a tracheoartery fistula

The goals of immediate management are to control bleeding and to maintain a patent airway while preparing the patient for primary surgical correction. Bleeding from a tracheoartery fistula complicating a tracheostomy usually occurs at one of three sites: the tracheostomy tube stoma, the tracheostomy tube balloon, or the intratracheal cannula tip. Bleeding at the tracheostomy stoma can sometimes be tamponaded by applying forward and downward pressure on the top of the tracheostomy tube. Bleeding at the site of the balloon can be tamponaded by overinflating the balloon. These maneuvers should be performed immediately. However, they will not be helpful if bleeding is occurring at the cannula tip. If the bleeding stops or slows either spontaneously or subsequent to these efforts, an endotracheal tube should be placed distal to the bleeding site. However, the initial tracheostomy tube should not be removed without a surgeon present because a sudden increase in the rate of hemorrhage may necessitate blunt dissection down the anterior tracheal wall posterior to the sternum to attempt direct digital tamponade of the bleeding site.

14 What is the role of bronchial artery embolization in the management of massive hemoptysis?

Bronchial artery embolization is important in the management of both surgical and nonsurgical causes of massive hemoptysis. It is a temporary measure for surgical lesions, facilitating the stabilization of patients while they undergo evaluation and preparation for surgery. It allows surgery to be performed in a more controlled setting. Bronchial artery embolization has become the primary mode of therapy for patients whose conditions are considered inoperable because of either diffuse lung disease or poor pulmonary function. Such patients may undergo multiple episodes of embolization over many years if hemoptysis recurs.

15 What is the success rate of bronchial artery embolization?

Various studies have reported success rates in the initial 24-hour period after embolization from 73% to 98%. However, 16% to 30% of patients have rebleeding in the first year after embolization. Rebleeding tends to be bimodal in occurrence, with peaks in the first month (generally because of inadequate initial embolization) and at 1 to 2 years (because of progression of underlying disease).

16 What complications are associated with bronchial artery embolization?

Bronchial artery embolization is associated with low morbidity rates. The most common complications include pleuritic chest pain, fever, leukocytosis, and dysphagia. These symptoms may last for 5 to 7 days. Other complications are quite rare and are related to the vascular compromise of organs supplied from vessels that arise downstream from the site of catheter placement. Examples include spinal cord infarction, transverse myelitis, bronchial stenosis, bronchial-esophageal fistula, transient cortical blindness, and cerebrovascular accidents.

17 When should surgery be considered in the management of massive hemoptysis?

Bronchial artery embolization has largely replaced surgical resection as the initial therapy in massive hemoptysis. Embolization is associated with much lower morbidity and early mortality rates than emergent surgery. However, because of high rates of recurrence after embolization, surgery should be considered for patients who have hemoptysis due to focal lung lesions and good pulmonary reserve after their conditions have been stabilized with embolization. Surgery is contraindicated in patients with advanced lung disease that results in limited pulmonary reserve, significant comorbidity (especially advanced heart disease), or lung malignancies invading the trachea, mediastinum, heart, great vessels, and parietal pleura. In contrast, it remains the treatment of choice for patients with hemoptysis related to trauma, aortic aneurysm, and bronchial adenomas.

18 Should fiberoptic bronchoscopy be performed before bronchial artery embolization in patients with massive hemoptysis?

For:

Fiberoptic bronchoscopy:

Against: