Haemoptysis Flashcards
Discuss pathophysiology of haemoptysis
Minor haemoptysis typically originates from the tracheobronchial capillaries that are disrupted by vigorous coughing or minor bronchial infection
Major haemoptysis almost always involves disruption of bronchial or pulmonary arteries
The bronchial arteries which are direct branches from the thoracic aorta are responsible for supplying oxygenated blood to the lung parenchyma – disruption of these vessels from arteritis, trauma, bronchiectasis or malignant erosions can result in sudden and profound haemorrhage,
Small and high pressure is the culprit in 90% of massive haemoptysis
Nearly all haemoptysis have a common mechanisms -vascular disruption within the trachea bronchi, small calibre airways or lung parenchyma
Difine massive haemoptysis
100-600 mls of blood loss in any 24 hour period – which can result in HD instability, shock or impaired alveolar gas exchange
TB and bronchiectasis are the most common causes of massive haemoptysis
Discuss DDX of haemoptysis
Airway disease
- bronchitis
- bronchiectasis * most common massive cause
- neoplasm
- trauma
- foreign body
Parenchymal disease
- TB
- Pneumonia, lung abcess
- Fungal infection
- Neoplasm
Vascular disease
- PE
- AVM
- Aortic aneurysms
- Pulmonary HTN
- Vasculitis (wegeners granulomatosis, SLE< goodpastures)
Haematological disease
- coagulopathy (cirrhosis or warfarin)
- DIC
- Platelt dysfunction
- Thrombocytopenia
Cardiac disease
- Congenital heart disease
- valvular heart disease
- endocarditis
Miscellaneous
- cocaine
- postprocedural injury
- tracheal-arterial fistula
- SLE
Discuss IX of massive haemoptysis
FBC, UEC, CMX, Coags
CXR
CT
Bronch early as if facilitates both localization of bleeding and therapeutic intervention
Discuss critical diagnosis not to miss
Critical
- if within 4 weeks of trachea placement tracheo-inominate (brachiocephalic trunk) artery fistula (TIF) must be considered
- DIC
- Aortobronchial fistula
- Iatrogenic haemoptyiss (post procedural)
- PE
Emergent diagnosis - Trauma -Bronchiectasis -Pneumonia -Abcess/ fungal infection -oral anticoagulant overdose endocarditis
Discuss management of massive haemoptysis
- Multple large bore peripheral access –
- Volume resuscitations should begin immediately with crystaloid until blood products are available
- Rotem guided massive transfusion
- TXA
- Reversal if on anticoagulation plus FFP
If TIF is suspected there should be an attempt made to overinflate the tracheostomy balloon in an effort to tamponade the bleeding - if this fails the trache should be removed and the operators index finger should be placed through the hole with pressure applied at the sight of bleeding
Patient with known or suspected lateralising source of bleeding should be placed nin the bleeding lung down position to protect the non bleeding lung from aspiration
Fibreoptic bronch in addition to being one of the first diagnositc techniques is also a first line therapeutic option as well
-Balloon and topical haemostatic tamponade, thermocoagulation and injection of vasoactive substance are all very effective
Bronchial artery embolisation is an effective first line therapy if interventional radiology is avialable
Emergency thoracotomy in the operaiting room is reserved for life threatening haemotpysis or for persistant rapid bleeding that is uncontrolled by bronch or embolization
Discuss RSI of massive haemoptysis
ENT, anaesthetics and respiratory – theatre as first option, fibreoptic may be difficult due to blood – likely C-mac best choice
H- fluid resus with products if available, pressors if need be
H- nil positive pressure as will force blood back into the lungs – normal nasal prongs
A- correct acid base if possible
R- respiratory conditions are likely optimised already until ETT placement and bronch can be performed
M- half dose induction agent – ketamine
S- sepsis not applicable
Patient sitting up prior to induction with dual suction – or bleeding lung down – double suction regardless
Large bore ETT to facilitate blood and thrombus extraction as well as interventional and diagnostic bronchoscopy
-If left side lung confirmed can consider right maining tube
-double lumen tube placed by anaethetics for single lung ventilation
Discuss granulomatosis with polyangiitis (Wegeners)
Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV) include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss)
Common presenting complaints – fever, weight loss, arthralgias, rhinosinusitis, cough and dyspnea
ENT - ottits media, ororrhea, rhinorrhae Pulmonary -- Pulmonary firbosis and HTN, dyspnoea, wheezing, haemoptysis Renal- asymptomatic haematuria Skin- Eye
Discuss goodpastures
Small vessel vasculitis in which ciruclating antiboides against an antiugen intrinsic to the GBM and alveolar basement membrane resulting in rapidly progressive glomeruloneprhitis and/or alveolar haemorrhage
Most people npresent with rapidly developing glomerulonephritis- between 25-60% of patients also present with concomitant alveolar haemorrahge and a small propritoin present with isolated lung finding
Diagnosis requires demonstration of anti GBM antibodies in the serum or the kidney – kidney biopsy should be performed unless there is a contraindications to do so
