Massive haemoptysis and desaturation Or how not to panic when it goes red Dr Diana Aguilar - February 2017

Overview Blood supply of the lungs Massive haemoptysis Definition Causes Management options Complications of bronchoscopy Prevention of potential complications Management of bleeding and other complications

1. Blood supply of the lungs 90% of cases of massive haemoptysis Bronchial artery Bronchial vein The bronchial artery supply blood to the bronchi and connective tissue of the lungs. They end at the level of the respiratory bronchioles. They anastomose with the branches of the pulmonary arteries, and together, they supply the visceral pleura of the lung Pulmonary artery Pulmonary vein

Bronchial arteries They supply In chronic inflammation: Lungs Visceral pleural Oesophagus In chronic inflammation: Enlargement and proliferation of bronchial arteries Recruitment of vessels from the systemic circulation Thin walled arteries and more likely to rupture

2. Massive haemoptysis No established definition, 200-600ml in 24 hours Rate more important than volume Any bleeding that impairs ventilation and gas exchange Bronchial artery in aprox. 90% of cases Death due to asphyxiation rather than exsanguination Mortality around 20%, but up to 80%

Non-massive haemoptysis Causes Massive haemoptysis Non-massive haemoptysis Bronchiectasis AVM Bronchogenic carcinoma PE Mycetoma Pulmonary hypertension Lung abscess Vasculitis Tuberculosis Trauma Eroding cavity Mitral stenosis Rasmussen Aneurism (PA) Iatrogenic

Goals of management Resuscitation Localisation Control Monitor Airway, breathing, circulation Consider need for intubation and double lumen ETT Oxygenation Nurse the patient with bleeding side down (if known) Cough suppression may help (morphine, codeine) IV access, clotting, platelets, X-match Tranexamic acid

Localise the source History and examination (?epistaxis/?haematemesis) Imaging CXR can be normal (20-26%) if source proximal CT angiography – bronchial artery Bronchoscopy (50-93% sensitivity) but can be challenging Safer after intubation Large bore suction channels Rigid bronchoscopy preferred if skills available

3. Control the bleeding: Isolate bleeding side if bleeding threatens other lung Tamponade via balloon catheter (Fogarty) Double-lumen ETT -Subsequent removal of the scope while the tamponading balloon remains in place -Potential for suctioning beyond the balloon for clearance of blood from distal airways

Bronchial artery embolisation Localise and control the bleeding The most effective 70- 90% 20% risk of re-bleed Complications: Spinal cord ischaemia Chest pain Dysphagia Case courtesy of Prof O Hennessy, Radiopaedia.org, rID: 33694

Surgical approach Best approach if embolisation not possible Spirometry (<50%) best predictor of surgical risk Most suitable treatment/curative for: Localised bronchiectasis AVM Aneurysm Aspergilloma Hydatid cyst Mortality 20-30%

Future options Surgicel/Surgifoam: Local tamponade Isolation at the segmental or sub-segmental bleeding site Absorption of blood Promotion of endobronchial clot formation by induction of fibrin polymerization.

Consider palliation: morphine, diazepam Monitor in HDU/ITU Consider palliation: morphine, diazepam If all measures fail If it is inappropriate to resuscitate the patient (advanced disease, Advance Directive, etc) Support and communication with patient, relatives and junior staff, can be a traumatic experience.

3. Complications of bronchoscopy Planning and prevention: Thorough patient assessment pre-bronchoscopy: Indication: is it appropriate? If previous bronchoscopy: Were there complications? Dose of sedation needed Consent Results: clotting, platelets, renal function, FEV1 Medications: anticoagulation, antiplatelets Comorbidities: asthma, COPD, DM, BMI, arrhtyhmias Available personnel and equipment (OOH FOB)

are essential in alerting of a deterioration Complications Respiratory depression Bronchoconstriction Hypoventilation Hypotension Syncope Bleeding (severe bleed <1%) Endobronchial biopsy: platelets > 50,000/μL More complex procedures, platelets > 75,000/μL. Routine oxygen and CVS monitoring are essential in alerting of a deterioration

Bleeding during bronchoscopy Suctioning Iced saline irrigation Laser coagulation Adrenaline Argon plasma coagulator (APC) Bronchoscopic tamponade Electrocautery Balloon tamponade – Fogarty balloon Double-lumen ETT tube Thrombin or fibrinogen instillation

Other complications Hypoxia: usually resolves with oxygenation and termination of the procedure. Brochosconstriction may require termination of procedure Respiratory depression, consider need for: NIV rescue Flumazenil (should be a “Never event”, so cautious sedation in at risk patients) Syncope: standard observations, ECG, BMs, etc

Summary The patient & You Massive haemoptysis is a medical emergency Step-wise approach: Resuscitation Localisation Control Monitor Team work to help you: * A&E * Radiology * ITU * Experienced anesthetist * Endoscopy team * Thoracic surgeons * Palliative care Thorough preparation pre-bronchoscopy Respiratory Spr saves the day! The patient & You

When it goes from this…. to this… to this…