Written By Laura Murphy
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ED management of massive hemoptysis should focus on resuscitation (including airway management, reversal of coagulopathy), diagnostic imaging, and prompt consultation or referral for definitive management.
Massive hemoptysis: don’t do it alone
Massive hemoptysis (MH) is any bleeding from the tracheobronchial tree that causes respiratory or circulatory compromise. While the most common worldwide cause is tuberculosis, the most common causes in U.S. include bronchiectasis, bronchogenic carcinoma, and mycetoma. Most cases (~90%) are associated with bleeding from the bronchial artery system (which are high-pressure arteries compared to pulmonary circulation). Patients with chronic pulmonary inflammation or masses are at risk due to increased fragility of bronchial arteries or erosion of masses into arteries. Death from MH is usually due to asphyxiation rather than hemodynamic compromise; anatomic dead space is ~150 mL in patients, so small amounts of blood can compromise oxygenation and ventilation. Diagnosis includes CT angiography with pulmonary arterial phase; contrast timing is different from standard study for pulmonary embolus, so you may need to call your radiologist! CXR can be helpful for unstable patients to lateralize bleeding, but 20-40% of radiographs are falsely negative. Bronchoscopy can help identify the source in patients with indeterminate CT. ED treatment should focus on airway management, resuscitation, and coagulopathy reversal. While coughing is the best way for patients to clear their airway, intubation is often indicated for airway compromise or respiratory distress. Anticipate difficulties due to bleeding; elevate the head of the bed and be ready with large-bore suction catheters, rescue devices, and surgical airway. A large bore ETT (8.5 mm or greater) is recommended, and copious suction is often needed. If bleeding persists, mainstem intubation of the unaffected side with single-lung ventilation should be used. Once intubated, patients can be turned into the lateral decubitus position with “bleeding lung down” to protect the lung that is not bleeding. Studies show that tranexamic acid is likely helpful in reducing bleeding; nebulized TXA should be administered to patients who can tolerate it, or IV TXA can be used for those who cannot tolerate nebulization. Definitive therapy includes bronchial artery embolization, bronchoscopy and surgical resection, which requires early specialty consultation from pulmonary, interventional radiology, or cardiothoracic surgery (or transfer to another center). Bronchial artery embolization has a high success rate and likely reduces mortality, but for central airway masses, this may not be an option. Bronchoscopy can localize a bleeding source and remove clots from the airway and may also provide therapeutic options by instilling agents to control bleeding or placing an endobronchial blocker.
How will this change my practice?
These patients are scary. In addition to managing airway and resuscitating patients, I will also incorporate TXA into my treatment algorithm. Imaging can be helpful to know who to call to manage these patients more definitively, but these are cases to “phone a friend” early.
Source
High risk and low incidence diseases: Massive hemoptysis. Am J Emerg Med. 2024 Sep 10;85:179-185. doi: 10.1016/j.ajem.2024.09.013. Epub ahead of print. PMID: 39278024.
How do you ascertain at the time of intubation which is the affected side? How do you know which side to mainstem intubate? Easier said than done. I have heard about double intubation ie placing one ETT and if fills with blood, mainstem that one (presumably it is the right given the anatomy and odds) and then place another tube down the L with bronchoscopic guidance. But if you are using an 8.5 Fr (which I wholeheartedly agree with), there ain’t going to be room for another, at least not easily (I’m sure there are some brave souls who would force it but not sure I’d want to). I know Anesthetists use double lumen tubes in CT surgery cases but I have never placed one of those and heard it can be difficult. These types of cases are not the time to be messing with new techniques one has no expertise in, so, again I am left wondering about how you determine which side is bleeding? And, no, I don’t mean in someone who is stable enough to get a CT before intubation. Thanks