6 Hemoptysis Flashcards
definition of massive hemoptysis
it varies
100 mL per 24 hours
>1000 mL per 24 hours
a midpoint value of 600 mL per 24 hours is accepted by many
90% of hemoptysis originates from
the bronchial arteries because it is a high pressure system
(although it only accounts for only 1% of blood flow to the lungs)
most common causes of potentially massive hemoptysis
parenchymal in origin, such as
* tuberculosis
* mycetoma
* neoplasm
*bronchiectasis
a false aneurysm of dilated blood vessels crossing the wall of a tuberculous cavity
Rasmussen’s aneurysm
remarks on neoplasms as cause of hemoptysis
neoplasms are protean and extensive, affecting airways and lung parenchyma while promoting neoangionesis
In particular, squamous cell carcinoma accounts for a large number of cases of massive hemoptysis
remarks on bronchiectasis
chronic disease states can lead to bronchiectasis (chronic bronchial wall inflammation), resulting in destruction of the cartilaginous support predisposing blood vessels to rupture
Hemoglobin may be falsely normal in acute, rapid bleeding as equilibration may not occur for
6 hours
remarks on CXR in hemoptysis
CXR is the initial imaging modality, yielding a diagnosis up to 50% of the time; in massive hemoptysis, the radiograph is rarly normal
Rasmussen’s aneurysm
a false aneurysm of dilated blood vessels crossing the wall of a tuberculous cavity
CT in hemoptysis
bronchial arteries are the main source of bleeding amenable to treatment and are almost always detected on multidetector CT
although CT angiography has been preferred for diagnosing pulmonary embolism, multidetector CT is preferred in evaluating massive hemoptysis
disposition of mild hemoptysis
disposition is dictated by
* amount of blood expectorated
* respiratory status
* risk factors for continued bleeding
CXR is negative –> suspect acute bronchitis –> appropriate antibiotics, then FU PCP
CXR is positive –> lung cancer or lung structural disease —> FU pulmo
remarks on intubation in hemoptysis
place the patient so the affected lung is in a dependent position to prevent spilling of blood into the unaffected side
if bleeding is uncontrollable, you may preferentially intubate the main bronchus of the unaffected lung
other options in securing airway in hemoptysis
Fogarty catheter (14F/100cm)
* preferentially tamponade affected lung 🔥
Cricothyrotomy
flexible vs rigid bronchoscopy
Flexible, fiberoptic bronchoscopy:
provides visualization of the more peripheral and upper lobes
but does not provide optimal suctioning and does not allow for local treatment
Rigid bronchoscopy
canno fully view the upper lobes and peripheral lesions,
but it offer greater suctioning ability and can provide treatment, such as the passage of Fogarty balloon catheters for tamponade of bleeding, epinephrine instillation, and ice water lavage
However, massive bleeding impairs visualization during bronchoscopy, compromising both diagnostic ability and treatment
surgery is reserved for
massive hemoptysis resulting from specific conditions including
* iatrogenic pulmonary artery injury
* thoracic trauma
* bleeding from a tracheoinnominate artery fistula at at tracheostomy site
