Continuing Education Activity

Pulmonary hemorrhage, also referred to as massive hemoptysis, is a potentially life-threatening condition involving bleeding from the pulmonary or bronchial vasculature which is usually due to higher pressure of the bronchial system. In cases where bronchial artery embolization has not yet been performed, mortality approaches 70 percent. Therefore, it is of critical importance to provide rapid evaluation, stabilization, and definitive care of the patient. This involves first determining whether the bleed etiology is of gastrointestinal or pulmonary origin. Intubation can protect the airway and preserve oxygenation and ventilation of the remaining functional lung. This activity reviews the evaluation of hemoptysis and identifies the role of the interprofessional team in managing this condition.

Objectives:

• Identify the causes of hemoptysis.
• Describe the evaluation of hemoptysis.
• Review etiologies of hemoptysis that require isolation precautions.
• Explain the role of interprofessional team members in optimizing collaboration and communication to ensure patients with hemoptysis are recognized early and every effort is made to deliver optimal care, which will lead to enhanced outcomes.

Introduction

Pulmonary hemorrhage, also referred to as massive hemoptysis, is a potentially life-threatening condition involving bleeding from the pulmonary or bronchial vasculature, of which the usual culprit is the higher pressure bronchial system.[1] Prior definition of pulmonary hemorrhage focused on classifications based on the rate and amount of overall blood loss which can be difficult to quantify.[1] Clinically, it may be of more utility to classify pulmonary hemorrhage by “magnitude and effect.”[2]

Because of the high mortality involved with this condition (up to 70% prior to use of bronchial artery embolization),[1] it is of paramount importance for the rapid evaluation, stabilization, and proper definitive care of the patient. This sequence involves first deciding whether the etiology is of gastrointestinal or pulmonary in origin. The decision to intubate or not requires rapid resolution to protect the airway and to oxygenate and ventilate remaining functional lung. Lastly, many times proper imaging is necessary in order to decide which service would perform the definitive care.

Etiology

The usual source of massive pulmonary hemorrhage is the bronchial vasculature. This high-pressure system is responsible for up to 90% of massive hemoptysis.[1] Other sources include aortobronchial fistulas, ruptured aneurysms, other non-bronchial sources (5%) and pulmonary vessels (5%).

The most common causes of massive pulmonary hemorrhage are (based on a retrospective cohort study of 1087 patients at a single tertiary hospital in France[3]):

• Tuberculosis (25%; with active being responsible for 12% and sequelae being 13%)
• Bronchiectasis (20%)
• Mycetomas (6%)
• Cryptogenic hemoptysis (18%)
• Bronchogenic carcinomas (17%)

Other sources include trauma and iatrogenic.

A more recent prospective Italian study of 606 patients from five Italian hospitals showed[4]:

• Lung cancer (19.1%)
• Pneumonia/lung abscess (18.6%)
• Bronchiectasis (14.9%)
• Acute bronchitis (13.7%)
• Tuberculosis (5%; active (3.3%) and sequelae (1.7%))

There is regional variation seen especially in countries where TB remains a strong concern. In this study and another Greek study bronchiectasis and neoplasms seem to be the leading cause of moderate-to-severe pulmonary hemorrhage (moderate defined as 20 to 500ml in 24 hrs; severe defined as greater than 500ml in 24 hrs).[5]

Epidemiology

At the single center French study,[3] median age was 54 years; 71% of the patients were male. Smoking was a feature in 71% of the patients.

The study by Mondoni et al. showed a median age of 67; 66.7% of the patients were male.[4] Smoking history was present in 54% of the patients. 

Pathophysiology

Tuberculosis: During active TB, bleeding is usually a result of ulcerations with subsequent necrosis of adjacent vessels.[6] In patients with a history of TB, it is often a consequence of the erosion of a calcified lymph node into a vessel and trachea, bronchiectasis secondary to the prior infection, or fungal infection in a cavity left from an earlier infection.[7] While the offending vessel is usually one of the bronchial arteries, occasionally there may be rupture of a Rasmussen’s aneurysm that comes off the pulmonary artery circulation.[8]

Bronchiectasis: Rupture of the tortuous vessels and hypertrophy due to chronic inflammation in the bronchial arterial system as well as blood vessels in the peribronchial and submucosal plexus.

Mycetomas: Most common organism is Aspergillus (50 to 90%) which is known to cause vascular and parenchymal changes in infection.[6]

Cryptogenic bleeding tends to occur in smokers.[9][10]

Carcinoma: Squamous cell carcinoma and other centrally located malignancies are either vascular sources themselves or erode into nearby vessels.[1]

Pneumonia: Invasive Fungal and bacterial pneumonias such as caused by Panton-Valentine leukocidin (PVL) producing form of MRSA. Pathogenicity of the PVL exotoxin is thought to be due to binding via a G-protein-coupled membrane-bound receptor that causes neutrophil adhesion to endothelial cells, capillary dilation, leukocyte migration, and vascular necrosis.

History and Physical

Discriminating between gastric and pulmonary sources of bleeding is important. Asking the patient whether the bleeding is from vomiting or coughing can sometimes help differentiate. A pertinent history will include the amount of blood loss, onset, fevers, history of TB infection or travel to endemic areas, smoking history, cancer history, night sweats, weight loss, and history of anticoagulation use. It may be pertinent to ask the patient's exertional status (i.e., ability to climb stairs or walk distances) before the episode, which may give an idea of whether or not the patient can functionally tolerate a lobectomy if indicated.[2]

Initial evaluation of the patient includes an assessment of the ABCs. Evaluate the patency of airway and check oropharynx for a proximal bleeding source. The bulk of the physical exam should focus on evaluating stability and ruling out any non-pulmonary source (i.e., hematemesis or epistaxis).[1] Capillary refill and skin evaluation can help with deciding if the patient needs an emergent transfusion of blood products. Lung exam may help determine if there is a unilateral source of the bleeding.

The exact amount of blood loss varies in the literature from 100 to 200ml, as it is extremely difficult to measure. It is important to remember that the anatomical dead space of an average adult is ~200ml. Therefore, the patient will present with distress, tachypnea, & hypoxia in the setting of an alarming amount of hemoptysis. This presentation should be enough to guide resuscitation rather than an attempt to measure and quantify blood loss.

Evaluation

A CBC with differential should be drawn to evaluate hemoglobin and hematocrit (H&H) and assess for thrombocytopenia. BMP should be drawn to evaluate for uremia as well as blood type and crossmatch and coagulation panel. A frontal chest radiograph should be obtained in an attempt to find a unilateral source. CXR can determine the site of bleeding 45 to 65% of the time and can determine the cause in 25 to 35%.[11] If the patient is stable, CT can be considered to delineate source and etiology. CT may be more sensitive than bronchoscopy, and some sources consider it the first line in the evaluation.[12][13][14][15][16]

Treatment / Management

If the CXR shows a unilateral source of bleeding or a known source from the H&P is found, place the affected side down to isolate bleeding and spare the remaining lung.[17][11] Other simple maneuvers include putting the patient in Trendelenburg or reverse Trendelenburg to isolate the source of bleeding further.[11]

If the decision is made to intubate, it is advisable to use at least an 8.0mm ID endotracheal tube (ETT) to allow subsequent use of bronchoscopy and bronchial blockers. Direct laryngoscopy is generally preferred over video laryngoscopy when there is significant bleeding. Attaching a meconium aspirator to the ETT may help with visualization. If bleeding is uncontrolled, it may be necessary to intubate the right main stem. If the bleeding is originating from the left side of the lung and there is no bronchoscope available, place the patient in right-lateral decubitus to shift the mediastinum to the right. In a study on 25 cadavers, intubaters were able to select the desired lung by first intubating the patient and then rotating the ET tube 90 degrees toward the desired side and advancing until resistance was met. This technique was found to be successful 72.3% of the time for the left lung and 94% successful for the right lung.[18] If attempts to select for the proper lung are unsuccessful, it may be possible to intubate the right main stem with a 5.0mm ET tube; this will allow either ventilation of the right lung if it is the unaffected side or isolation of the right lung if it is the hemorrhaging side. If indeed the right lung is the affected side, the 5.0mm ET tube should be small enough to allow placement of another ET tube to the left lung for ventilation. To properly control the soiled airway, approaches such as SALAD and double suction have been developed(Kovach et al. Airway Management in Trauma. 2018 https://doi.org/10.1016/j.emc.2017.08.006.).

Reversals: If the patient is on anticoagulation, reversal of any medication is paramount to assist in achieving hemostasis

TXA: With the success of the WOMAN and CRASH-2 trial in post-partum hemorrhage and trauma, respectively, there has been some case reports of the use of IV TXA or nebulized TXA in pulmonary hemorrhage with some success.[17] A recent RCT of 47 patients showed 96% resolution of hemoptysis in 5 days with inhaled TXA 500mg TID versus the placebo group (NS) (50%). Of note, patients with hemoptysis greater than 200ml in 24 hours, or with hemodynamic or respiratory instability were excluded.[19]

Double Lumen tubes: Double lumen tubes are generally not recommended for a myriad of reasons.[2] The bronchoscope used to place the double lumen does not have adequate suction channels to give clear visualization in the face of massive bleeding or ability to suction out large clots. The double lumen ETT only allows pediatric bronchoscope and not therapeutic bronchoscopy. It also does not allow evaluation of the proximal airways. Placement of the double lumen ETT is more time consuming and requires more expertise; this may be difficult to assemble in a time of crisis.

Fiber-optic bronchoscopy (FOB): Allows for visualization of the source of bleeding, clearing airway of bleeding and clots (especially in the non-bleeding lung). Visualization of the bleeding source is essential to enable hemostatic techniques such as a bronchial blocker placement later. Many times in large scale bleeding, FOB is necessary for proper intubation of the non-bleeding lung. It can be used to wedge into the bleeding site to create tamponade.

Rigid Bronchoscopy: Allows of simultaneous evaluation of bleeding source and ventilation of non-bleeding lung. The large channels of this device can accommodate additional suction catheters as well as FOB for visualizations. The rigid bronchoscope also allows the user to use the full array of intrabronchial therapeutic techniques.

Bronchial blocker: This device allows for simultaneous ventilation of clear lung as well as tamponading off the bleeding side of the lung. The device is usually inserted with the assistance of a FOB through an ETT and allows for insertion of a cuffed catheter that can tamponade the bleeding lung; it is usually inserted into the main stem bronchus or bronchus intermedius.[20] This method allows for temporary hemostasis until rendering further definitive treatment. When a commercial device is not available, some clinicians have described successful placement of a Fogarty catheter through the channel of a FOB, which can also be introduced besides the ETT.[17]

Intrabronchial treatments: These include cold saline lavage, epinephrine injections, spigots, cellulose mesh, ADH derivatives introduced through either FOB or rigid bronchoscope. If a definitive source of bleeding is present and reachable, electrocautery, cryotherapy, laser, argon plasma coagulation is also an option.[2]  

Bronchial Artery Embolization (BAE): Definitive treatment if bleeding is from the bronchial artery system (approximately 90% of the time), it is often considered the first line management in massive pulmonary hemorrhage. Success rates are up to 90% in the right patient population.[21][22] Actual active contrast extravasation is only seen in 10 to 15% of cases, and site selection is usually based on radiographic signs of hyper-tortuosity, artery hypertrophy, aneurysms or AVM formation.[21][22][23] Once found, suspected sources of bleeds are embolized via microspheres, gelatin sponges, or coils. Re-bleeding will occur in approximately 30% of patients within 30 days,[22] and thus lobe resection in appropriate candidates should be a consideration. With current technology, the complication of anterior spinal artery embolization is as little as between 0 to 1%.[11]

Surgery: Resection is considered last resort for management of pulmonary hemorrhage largely due to high mortality rates. Based on a study by Adrejak et al., mortality rates of 35% were seen in emergent resections, and significantly decreased mortality rates of 4% in resections scheduled after hemostasis and 0% in resections scheduled for after discharge.[24] Therefore, it may be prudent to provide temporary hemostasis, if possible, to avoid emergency resection; this allows for optimization of the patient medically and more time allowed for adequate evaluation of the extent of resection needed.[2]

Differential Diagnosis

• Aspergilloma

• Alveolar haemorrhage

• AV malformation

• Bronchitis

• Bronchiectasis

• Coagulopathy

• Emboli (pulmonary)

• Lung abscess

• Mitral stenosis

• Tuberculosis

• Tumour

Enhancing Healthcare Team Outcomes

There are many causes of pulmonary hemorrhage, and further, the disorder can be mistaken for hematemesis; thus the condition is best managed by an interprofessional team. Also, the treatment of the situation requires experience. The key is control of the airways, and thus an anesthesiologist and a thoracic surgeon should be consulted immediately. The outlook will depend on the cause.