Massive Hemoptysis

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Chapter 26 Massive Hemoptysis

Hemoptysis is the coughing up of blood or bloodstained sputum. Massive hemoptysis is variably defined as 200 to 1000 ml of blood expectorated in 24 hours; 600 ml is a widely accepted figure.1,2 Blood loss is rarely measured and is difficult to quantify. A more practical definition of massive hemoptysis is that which is acutely life-threatening. Although massive hemoptysis is uncommon, it is potentially lethal and has a mortality rate of between 9% and 59%.1 The management of patients with massive hemoptysis requires a team approach, with involvement from specialists in intensive care, pulmonology, interventional radiology, and thoracic surgery.

ETIOLOGY

The causes of massive hemoptysis are listed in Table 26-1. Tuberculosis is the most common cause worldwide, but in developed countries chronic inflammatory lung diseases (e.g., bronchiectasis) and lung cancer are the most common causes.

Table 26-1 Causes of Massive Hemoptysis

Neoplastic Bronchial carcinoma
  Metastatic lung cancer
  Leukemia
Infectious Bronchiectasis
  Bronchitis
  Tuberculosis
  Fungal infections
  Paragonimiasis (parasitic lung fluke)
  Hydatid cyst
Vascular Pulmonary infarction or embolism
  Mitral stenosis
  Bronchoarterial fistula
  Rupture of a thoracic aortic aneurysm
  Arteriovenous malformation
Vasculitic Wegener granulomatosis
  Behçet disease
  Goodpasture syndrome
  Systemic lupus erythematosus
Miscellaneous Anticoagulant therapy
  Coagulopathy
  Trauma
  Lymphangioleiomyomatosis
Iatrogenic Pulmonary artery rupture secondary to a pulmonary artery catheter
  Malposition of a chest drain
  Tracheoarterial fistula

Adapted from Jean-Baptiste E: Clinical assessment and management of massive hemoptysis. Crit Care Med 28:1642-1647, 2000.

In the majority of cases massive hemoptysis is caused by bleeding from branches of the bronchial arteries. Bleeding from branches of the pulmonary artery accounts for less than 10% of cases. Occasionally, microvascular (alveolar) bleeding occurs secondary to an immune-mediated vasculitis.

There are normally three bronchial arteries, one on the right and two on the left. The right-sided artery usually arises from the third posterior intercostal artery, whereas the two left-sided arteries usually arise directly from the aorta. The bronchial circulation normally receives less than 1% of the cardiac output, but with chronic inflammatory lung disease, the bronchial vessels undergo marked proliferation and this percentage increases. Because the bronchial arteries are part of the systemic circulation, bleeding from these arteries tends to be more dramatic than that from the lower pressure pulmonary arterial system. Bronchial arterial bleeding is almost always the source of bleeding in patients with chronic inflammatory lung disease. It may be controlled by bronchial arterial embolization and vasoactive drugs.

Pulmonary arterial bleeding tends to occur because of ulceration of the vascular wall due to a locally destructive process, such as necrotizing lung cancer, necrotizing pneumonia, or a cavitating aspergilloma, and it is less amenable to control by vasoactive substances or embolization. However, these conditions more commonly cause bronchial artery bleeding. Evidence of pulmonary arterial bleeding may be obtained from the circumstances (e.g., following manipulation of a pulmonary arterial catheter) or from a negative bronchial arteriogram. Hemoptysis that occurs following lung transplantation is due to pulmonary arterial bleeding because the bronchial arteries are not reimplanted at the time of surgery.

DIAGNOSIS AND TREATMENT

As in all situations in which a patient develops an acute critical illness, diagnosis and treatment must proceed in parallel. An algorithm for the diagnosis and management of massive hemoptysis is provided in Figure 26-1.