Massive Hemoptysis

 

 

Considerations

 

  • Emergency, full stomach, limited time to optimize

  • Etiology of hemorrhage & patient comorbidities:

    • Infection (tuberculosis), bronchiectasis, malignancy, arteriovenous malformation, pulmonary artery catheter, trauma

  • Difficult airway & requirement for rapid lung isolation to prevent contralateral contamination & asphyxia

  • Facilitation of subsequent definitive treatment: bronchial artery embolization, lung resection

  • Resuscitation of hemorrhagic shock

 

 

Goals

 

  • Prompt mobilization of resources (OR, surgeon, interventional radiology) & effective communication between various parties

  • Rapid management: airway protection, resuscitation & stabilization, localization of bleeding site, & administration of specific therapy

  • Rapid isolation of non-bleeding lung (double lumen tube vs bronchial blocker vs endobronchial intubation; bleeding lung down)

  • ↓ bleeding: bleeding lung up after selective bronchial intubation (↓ effective pulmonary artery pressure on that side), CPAP to bleeding lung (for tamponade effect), reversal of anticoagulation

  • Optimization of oxygenation & ventilation to both lungs (good lung down, CPAP to bleeding lung)

 

 

Management

 

  • Mobilize resources, call thoracic surgery

  • Monitors, large IVs x2, 100% O2

  • Lateral position with bleeding side down

  • Call for blood, resuscitate if hemodynamically unstable, correct coagulopathy

  • Secure airway if problems with gas exchange:

    • Best done in the OR with thoracic surgeon/rigid bronchoscope available

    • Awake intubation vs RSI

    • Double lumen tube vs single lumen tube endobronchially or with bronchial blocker

  • High frequency jet ventilation may be life saving

  • Suction, suction, suction

  • Once isolated, CPAP to bleeding side may help tamponade the bleeding site

  • May need to urgently go to OR for rigid bronchoscopy or thoracotomy