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

2. 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

3. 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

4. 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

5. 2. Massive haemoptysis
No established definition, ml 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%

6. 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

7. 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

8. 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

9. 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

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

11. 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%

12. 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.

13. 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.

14. 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)

15. 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

16. 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

17. 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

18. 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

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