Hemoptysis

Question 1

Pulmonary vs bronchial circulation

Answer 1

Pulmonary: comes to the lungs to get oxygenated
Bronchial: blood supply of the airways

Question 2

What blood supply is usually responsible for hemoptysis

Answer 2

Bronchial

Question 3

Most common cause of hempotysis

Answer 3

Inflammation of the tracheobronchial mucosa

Question 4

3 main causes of massive hemoptysis

Answer 4

TB
Bronchiectasis
Carcinoma

Question 5

4 steps in general management of hemoptysis

Answer 5

Obtain history
Physical exam
Lab investigations
Management and intervention

Question 6

Most important question to ask when taking history

Answer 6

How much blood?

Question 7

What is the best way to diagnose

Answer 7

Combined bronchoscopy and CT

Question 8

Rigid bronchoscopy

Answer 8

Secures the airway
Large port, greater suction
Limitation: OR/anesthesia, expertise needed

Question 9

Flexible bronchoscopy

Answer 9

Ease of use, availability
Greater visualization of peripheral airways
Limitations: small port, decreased suction, decreased visualization

Question 10

When should you do bronchoscopy?

Answer 10

Early and when they are actively bleeding

So that you can find the bleed and do something about it

Question 11

Why do you use CT and bronch?

Answer 11

CT provides road map for bronchoscopist and diagnostic information
Bronch allows for tissue sampling and direct intervention
CT should precede bronch, but not appropriate in massive or unstable hemoptysis

Question 12

Should you use a double lumen ET tube for massive hemoptysis?

Answer 12

No
Small individual lumens hinder bronch
Unable to effectively aspirate secretions/blood
Difficult to place and secure

Question 13

Endobronchial tamponade

Answer 13

Direct tamponade effect
Leave balloon inflated for 24 hours and then deflate for observation
After no observed bleeding leave in situ deflated for another 24 hours

Question 14

3 topical therapies

Answer 14

Cold saline irrigation
Vasoconstrictive agent (epi)
Topical coagulants (fibrinogen, thrombin)

Question 15

2 physical ways to stop the bleeding

Answer 15

External beam radiation (but takes a few days)

Argon plasma coagulation

Question 16

Argon plasma coagulation

Answer 16

Burn the tissue so it stops bleeding
Argon gas ignited by electric spark
Benefits: good hemostasis, can treat lesions lateral to or around corner from tip of catheter, safe use near metallic stents
Limits: delayed tissue effects, may need debridement 48hrs later
Risk: airway fire, air embolism

Question 17

Bronchial artery embolization

Answer 17

Inject dye into arteries, take X-rays to visualize bleed, inject particles to stop the bleeding
Mainstay of treatment now

Question 18

How much blood in massive hemoptysis?

Answer 18

400mL in 24 hours

Question 19

What size ET tube should you use to intubate?

Answer 19

8.0