Massive haemoptysis is rare but carries with it a high mortality. Any amount of blood loss in excess of 100 mL in 24 hours may constitute massive haemoptysis. Some patients may expectorate several litres of blood per day. The risk to life is from respiratory compromise due to the tracheobronchial tree filling with blood rather than from hypovolaemia and haemodynamic deterioration.
Aetiology of massive haemoptysis
The causes of massive haemoptysis are listed in Causes of massive haemoptysis. The majority are benign inflammatory or infective lung disorders. Malignancy seldom presents with massive bleeding.
The source of bleeding is nearly always the high pressure bronchial circulation. These vessels are often enlarged in response to the primary pathology (e.g. bronchiectasis) or are involved in the inflammatory or necrotic process (e.g. tuberculosis). The pulmonary arterial circulation is the source of bleeding from arteriovenous malformations.
A thorough history and examination is required bearing the possible causes in mind. Epistaxis and haematemesis must be excluded. Any anticoagulant intake should be established. A history of fever, night sweats, weight loss, previous tuberculosis or an exposure to tuberculosis may suggest active tuberculosis. Recurrent pulmonary infections may point to bronchiectasis. Helpful physical signs may include finger clubbing, peripheral or cervical lymphadenopathy and localised wheeze, crepitations, or consolidation. Abnormal respiratory signs may be absent if the blood is effectively expectorated.
The investigations for massive haemoptysis are listed in Investigations of massive haemoptysis. A chest X-ray may be completely normal if little blood is retained within the airway. Infection or tumour may be localised but shadows of aspiration may be confusing. Serial chest X-rays may be helpful. Bronchoscopy, performed while bleeding is occurring, is the best way to localise the source. The rigid instrument provides a superior view and facilitates airway suction and bronchial toilet. Occasionally the flexible instrument may be passed through the rigid bronchoscope to visualise more peripheral lung lesions. If the patient is fit enough to tolerate computed tomography scanning, the majority of causes of massive haemoptysis will be demonstrated. Bronchial angiography and possible embolisation may have a role in high-risk surgical patients where initial bronchoscopy has been unhelpful.
The key principles in the management of this potentially fatal condition are:
- prompt early resuscitation
- precise localisation of the bleeding source
- definitive therapy.
The patient requires intensive care monitoring of vital signs and oxygen saturation. The patient should be positioned head down and bleeding side down (if known). Adequate amounts of blood should be available for administration via a large-bore intravenous line based on haemodynamic parameters rather than the amount of blood lost (notoriously unreliable). Broad-spectrum antibiotics should be given pending results of sputum cultures. Specific antituberculosis therapy is added in the presence of active tuberculosis.
Rigid bronchoscopy is vital to maintain the airway, aspirate blood and secretions from the airway and for ventilation. After localising the source of bleeding, control may be obtained by ice-cold saline lavage (leading to vasospasm) or placement of an endobronchial balloon blocker and endotracheal intubation. Patients are ventilated (with positive end-expiratory pressure) and bronchoscopy is repeated 12 to 24 hours later to assess ongoing bleeding prior to definitive therapy.
Definitive therapy may include one or more of the following:
- medical therapy: antibiotics, reversal of anti-coagulation
- surgical resection (immediate or after initial control of bleeding source)
- angiography and arterial embolisation (for arteriovenous malformations; up to 20% incidence of rebleeding, so should be followed with surgical resection)
- radiotherapy (for non-resectable tumours or if patient is unfit for surgery).
Massive re-bleeding can occur following the initial establishment of control. Surgical resection of the lesion, therefore, offers the best hope of cure. All endobronchial and angiographic therapies should be considered temporary answers to this problem. Surgical resection is contraindicated in patients with severe cardiorespiratory dysfunction, uncorrectable coagulopathy, unresectable cancer and in those in whom the bleeding site is impossible to localise by any method.
Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis. Clin Chest Med. 1999;20:89–105.
Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28:1642–1647.
Corder R. Haemoptysis. Emerg Med Clin North Am. 2003;21:421–435.Jougon J, Ballester M, Decambre F, et al. Massive haemoptysis: What place for medical and surgical treatment. Eur J Cardiothoracic Surg. 2002;22:345–351.