Download Management of life‐threatening haemoptysis

Management of life-threatening haemoptysis
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British Journal of Anaesthesia 88 (2): 291±5 (2002)
Management of life-threatening haemoptysis
E. HaÊkanson1*, I. E. Konstantinov2, S.-G. Fransson3 and R. Svedjeholm2
1
3
Departments of Cardiothoracic Anaesthesia and Intensive Care, 2Cardiothoracic Surgery and
Thoracic Radiology, LinkoÈping Heart Center, University Hospital, SE-581 85 LinkoÈping, Sweden
*Corresponding author
Massive haemoptysis represents a major medical emergency that is associated with a high
mortality. Here we present two cases of life-threatening haemoptysis, the ®rst caused by rupture of an aortic aneurysm into the lung in a 37-yr-old woman with polyarteritis nodosa and
the second caused by massive bleeding from an angiectatic vascular malformation in the right
main bronchus in a 21-yr-old woman. Fibreoptic bronchoscopy played an essential role in the
diagnostic process and management of the respiratory tract. Diagnosis in the ®rst case was
obtained by CT scan and the aneurysm was treated surgically. In the second case, bronchial
arteriography contributed to both de®nitive diagnosis and treatment. Initial cardiorespiratory
management, diagnostic procedures and de®nitive therapy are described and reviewed.
Adequate early management of the cardiorespiratory system is essential to the outcome.
Aggressive measures to elucidate the cause of haemoptysis and prompt therapy are warranted
because of the high risk of recurrence.
Br J Anaesth 2002; 88: 291±5
Keywords: arteries, aortic aneurysm; blood, massive haemoptysis; lung, angiectasia;
monitoring, bronchial arteriography; surgery, bronchoscopy
Accepted for publication: October 10, 2001
Massive haemoptysis represents one of the most challenging conditions encountered in critical care. It is
reported to carry 30±85% mortality in non-trauma
patients.1±5 Experience in the management of these
cases is limited in Western countries because of the
control of tuberculosis and infective respiratory disease.
However, when encountered, adequate early management
of the cardiorespiratory system is essential to the
outcome. Moreover, aggressive measures to elucidate
the cause of haemoptysis, together with prompt therapy,
are warranted because of a high risk of recurrent lethal
bleeding. Here we present two cases of massive
haemoptysis, which illustrate some essential issues in
the management of this condition, and review the
literature.
Case reports
Patient 1
A 37-yr-old woman was admitted to a neighbouring hospital
with massive haemoptysis. She had a long history of
polyarteritis nodosa. During the 3 months before the
admission she suffered from frequent episodes of coughing.
Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
HaÊkanson et al.
Fig 1 Case 1: the chest radiograph showed alveolar opacities in the left
lung, stenosis of the left main bronchus and a suspected aortic aneurysm.
Fig 2 Case 1: the CT scan was diagnostic and showed an aneurysm of
the descending aorta, with a calci®ed aortic wall and suspected rupture
into the lung.
Fig 3 Case 2: chest radiograph showing the double-lumen tube and
extensive in®ltrates in both lungs resulting from massive bleeding.
Emergency repair of the aneurysm through a left posterolateral thoracotomy was undertaken. The operation was
performed on cardiopulmonary bypass and the aorta reconstructed with a Hemashield dacron graft. The rupture in the
upper lobe of the left lung was sutured. The patient's trachea
was extubated on the day after surgery but shortly
afterwards had to be reintubated for a further day.
Bronchoscopy and suction were required to clear the
airways. The postoperative course was otherwise uneventful, and the patient was discharged on the 18th postoperative
day. Two and a half years later the patient underwent
uneventful prophylactic surgery with reconstruction of the
ascending aorta because of progressive dilatation of the
ascending aorta. Histological examination of the resected
aneurysm revealed atherosclerosis but no signs of polyarteritis nodosa. On follow-up 5 yr later she remained free
from haemoptysis.
Patient 2
Upon admission she was intubated; however, attempts to
insert a double-lumen tube failed because of stenosis of the
left main bronchus. Chest radiography revealed opacities in
the left lung (Fig. 1). Because of recurrent haemoptysis with
an estimated blood loss exceeding 1000 ml, the patient
required blood transfusion and ¯uid replacement. Following
cardiovascular stabilization, the patient was transferred to
the University Hospital. Fibreoptic bronchoscopy revealed
an 80% stenosis of the left main bronchus and bleeding from
the left lung. Endotracheal intubation with a right-sided
double-lumen tube (Broncho-Cath, Mallinckrodt Medical
Ltd, Athlone, Ireland) was accomplished. CT scan showed a
large aneurysm of the descending aorta (15 cm diameter)
that had ruptured into the upper lobe of the left lung (Fig. 2).
A 21-yr-old, previously healthy woman was admitted to
her local hospital with massive haemoptysis that started
suddenly 2 h prior to admission. On admission she was
in haemorrhagic shock and received a 2000 ml blood
transfusion. Her trachea was immediately intubated with
a single-lumen endotracheal tube. Chest radiography and
CT scan showed extensive alveolar in®ltrates in both
lungs. Emergent ®breoptic bronchoscopy failed to
localize the side of bleeding because of ¯ooding of
the ®eld with blood.
The patient was transferred to the University Hospital.
Upon admission she was haemodynamically stable but
presented with an arterial oxygen saturation of 70%.
Fibreoptic bronchoscopy was repeated to clear the airways
292
Management of life-threatening haemoptysis
Fig 4 (A) Selective angiography revealed a suspected bleeding from one of the bronchial arteries (bottom), and one normal bronchial artery (top).
(B) Schematic drawing; arrows show two aneurysmal dilatations.
of blood and clots, and to localize the source of bleeding. A
slightly elevated bluish structure in the right main stem
bronchus was found, which was thought to be a vascular
malformation. After intrabronchial infusion of epinephrine,
tranexamic acid and iced saline lavage, the bleeding
diminished. Thereafter a left-sided double-lumen tube
(Broncho-Cath, Mallinckrodt Medical Ltd, Athlone,
Ireland) was sited (Fig. 3). To reduce the risk of rebleeding, the patient also received desmopressin and
tranexamic acid systemically.
Selective bronchial and intercostal artery angiography,
aortography and bilateral angiography of the internal
thoracic arteries were performed. They revealed two small
aneurysmal dilatations and con®rmed the suspicion of
bleeding from a vascular malformation of the bronchial
arteries (Fig. 4). An intimal dissection of the bleeding
bronchial artery was caused during attempts to achieve
therapeutic embolization. This, however, permanently
stopped the bleeding.
The patient required prolonged mechanical ventilation
and even ECMO was considered because of hypoxaemia. However, the patient slowly improved and was
discharged to the ward after 34 days in the ICU. Later
evaluation for a systemic generalized disorder or
hereditary trait was negative. It was assumed that the
bleeding had resulted from congenital aneurysmal malformations of the bronchial artery. The patient was in
good health on 3-yr follow-up.
Discussion
These case reports illustrate the importance of respiratory
management and early diagnosis for correct de®nitive
treatment in life-threatening haemoptysis. Death from
haemoptysis is rarely caused by exsanguination, but rather
by asphyxia resulting from ¯ooding of the airways and
alveoli with blood.6 In our ®rst patient the source of
haemoptysis was a ruptured aneurysm of the descending
aorta. The second case illustrates a typical cause of massive
haemoptysis in young healthy individuals. The clinical
course was complicated because of the magnitude of
bleeding from the respiratory tract, which initially also
threatened the circulatory state of the patient and caused
protracted pulmonary dysfunction requiring mechanical
ventilation for a month.
The de®nition of massive haemoptysis varies from
100 to 600 ml of blood loss per 24 h.1±4 6±8 In our
opinion, quanti®cation of haemoptysis may be dif®cult
and, from a clinical point of view, such criteria are
not useful. Obviously, haemoptysis that jeopardizes
respiratory function should be treated as a medical
emergency.
Initial management
The ®rst priorities in treating the patient with life-threatening haemoptysis are to maintain the airway, optimize
293
HaÊkanson et al.
oxygenation and stabilize the haemodynamic status.
Intubation with a single-lumen endotracheal tube is recommended until the bleeding is localized. In patients with
lateralized or localized persistent bleeding, immediate
control of the airway may be achieved by insertion of a
double-lumen endobronchial tube to isolate and ventilate
the lungs separately, or by endobronchial tamponade with,
for instance, a Fogarty catheter.7 9±12
Selective main-stem intubation into the uninvolved
bronchus to protect the contralateral side is an alternative
to the double-lumen tube if the bleeding side is known.
However, with this method there is loss of access to the side
of bleeding for suctioning and bronchoscopic examination.
The need to clear the airways of blood and clots should
in¯uence the decision in the choice of tubes, as clearance of
blood is more dif®cult through the double-lumen tube.
Furthermore, a normal ®breoptic bronchoscope cannot be
introduced through a double-lumen tube and the risk of
occlusion by clots must be considered. Our second patient
®rst received a single-lumen endotracheal tube and later,
when the bleeding source had been identi®ed, a doublelumen tube was introduced.
When the side of bleeding is identi®ed it is generally
accepted that the patient should be placed with the bleeding
side down to prevent aspiration into the uninvolved lung.
Systemic therapy directed at improving coagulation deserves consideration. Also, bronchoscopy may be useful for
topical haemostatic treatment.13
Diagnostic procedures
Occasionally in life-threatening haemoptysis the
treatment has to be based on presumptive, rather than
conclusive, diagnosis. It is essential to achieve early
identi®cation of which lung or lobe/segment is the source
of bleeding.
Bronchoscopy, preferably during active bleeding, should
be performed to lateralize the bleeding side, to identify the
part of the lung that may have to be urgently excised and, if
possible, to identify the cause of the bleeding.7 Rigid
bronchoscopy obviously provides better scope for suctioning but does not generally allow visualization of upper lobes
and peripheral lesions. The two methods of bronchoscopy
can be used in conjunction with one another by passing the
®breoptic bronchoscope through the rigid instrument.7 In
our ®rst patient, the bleeding lung was identi®ed by means
of ®breoptic bronchoscopy; in the second, a presumptive
diagnosis was made at the second attempt. Major ongoing
bleeding in the lungs can render it impossible to identify or
even lateralize the bleeding with ®breoptic bronchoscopy.
In both patients, however, ®breoptic bronchoscopy contributed to the successful management of the respiratory
tract. The choice of bronchoscopy method depends not only
on the situation of the patients but is also in¯uenced by
availability of special equipment and expertise. Both our
patients were intubated. We therefore considered it advis-
able to use ®breoptic bronchoscopy. Furthermore, ®breoptic
bronchoscopy can be performed at the patient's bedside.
However, as mentioned earlier, the availability of expertise
determines the method in the immediate management of
these patients. Use of the rigid bronchoscope is declining
and fewer institutions are now providing training in this
technique.7 Repeated ®breoptic bronchoscopy with instillation of cold epinephrine±saline in intubated patients with
life-threatening haemoptysis was successful in 6 out of 7
patients.13
Chest radiography and CT scan are also useful diagnostic
tools. In our ®rst patient a CT scan demonstrated an
aneurysm of the descending aorta that had ruptured into the
left lung (Fig. 2). However, the site of intra-bronchial
haemorrhage is localized with reasonable con®dence in only
63% by a combination of these diagnostic techniques.1
The lungs have a dual vascular supply, being served by
both the pulmonary and bronchial circulations. Selective
bronchial arteriography is an important diagnostic technique
with therapeutic applications in these cases.14 In our second
patient, bronchial arteriography con®rmed the suspicion of a
vascular malformation. Occasionally, pulmonary angiography has to be considered, such as in suspected pulmonary
embolism or Rasmussen's aneurysm.15 16
Echocardiography may reveal rare cardiac causes of
massive haemoptysis such as bacterial endocarditis or mitral
stenosis.17 18 Infectious, vasculitic and other systemic
diseases should not be overlooked in the search for the
cause of bleeding.1 2 19
Causes and treatment
Outside the Western world, tuberculosis remains the most
common cause of massive haemoptysis.1 The majority of
the patients have bronchiectasias or cavitation. In Western
countries, however, neoplastic disease of the lung is the
most common cause of massive haemoptysis.6 Other major
causes of massive haemoptysis include aspergilloma and
bronchiectasias.6 20
A history of haemoptysis in association with menstruation suggests pulmonary endometriosis.21 Haemoptysis in
the early postoperative period should suggest the possibility
of injury to the pulmonary vessels by a Swan±Ganz
catheter.11 22 Haemoptysis may occur as a late complication
of surgical procedures such as pseudoaneurysms after aortic
graft surgery or because of retained foreign bodies after
pulmonary procedures.23 24
De®nitive treatment depends on the cause and anatomical
localization of massive haemoptysis. As in our ®rst patient,
bleeding from large systemic arteries and aneurysms into
the bronchial tree necessitate immediate surgery.17 25 26
Endovascular stents may provide an alternative to surgery in
selected cases.23 Bleeding from bronchial or other small
systemic arteries is treated preferably by selective embolization, as was attempted in our second patient.14 27 A
thorough understanding of bronchial arterial anatomy is
294
Management of life-threatening haemoptysis
required to avoid potential complications, in particular
transverse myelitis.28 29 Immediate control of haemoptysis
by bronchial artery embolization has been reported in
between 75% and 90% of patients.14
In conclusion, massive haemoptysis should be considered as a life-threatening medical emergency. A well
co-ordinated strategy involving different medical and
surgical specialists is required for successful management. Control of the respiratory tract is the ®rst priority
and should be followed by aggressive measures to
identify the source of bleeding, and prompt treatment.
Because of the high incidence of recurrent haemoptysis,
these patients should not be discharged from hospital
before the de®nitive diagnosis and, if possible, de®nitive
treatment.
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