Few conditions in pulmonary medicine evoke such a horrifying experience for a clinician as the encounter with a patient who is acutely and actively expectorating bright red blood, and the sight of the patient turning pale and anxious, and gasping for air. For experienced and inexperienced clinicians alike, massive hemoptysis requires an immediate response and intervention. Blood loss and hypovolemia may be managed by blood product and volume replacement. Asphyxiation may be more of a problem acutely than exsanguination in a patient with acute and massive hemoptysis. The volume of the central conducting airway (dead-space) measures only approximately 150 mL. The central conducting airway can fill rapidly with blood and blood clots during massive hemoptysis. If this occurs, ventilation and oxygenation are compromised. The sight of expectorated blood combined with the dyspnea from compromised ventilation may also raise the anxiety level of the patient, sometimes to the point of agitation, making the management of the patient even more challenging.
Hemoptysis has been variably classified. Massive hemoptysis has been defined as expectoration of blood ranging from 100 to 1,000 mL a day. Although the estimated volume of expectorated blood in 24 hours may be useful in classifying the severity of hemoptysis, the rapidity of the blood loss and the general condition of the patient are very important in deciding the level of intervention needed. For example, a patient who expectorates 200 mL of blood in 24 hours, but the bulk of which occurred during the last 10 minutes, may present with a potentially more acute problem than another patient who expectorates a total of 200 mL of blood in 24 hours in small amounts regularly throughout the day. The clinician should not miss the beginning of a large bleed by fixating solely on the 24-hour volume definition of hemoptysis, because a life-threatening massive hemoptysis may be heralded by continuous small bleeds. Crocco et al. 1 reported a mortality of 71% in patients with 600 mL of hemoptysis occurring in less than 4 hours, 22% in patients with 600 mL of hemoptysis occurring in 4 to 16 hours, and 5% in patients with 600 mL of hemoptysis occurring in 16 to 48 hours.
In general, it is not difficult to recognize the difference between a stable patient with occasional blood-streaked sputum and the patient with massive hemoptysis described earlier. The former allows the clinician to perform a complete evaluation with detailed pulmonary history, physical examination, and ancillary studies. The latter requires a mode of active resuscitation in conjunction with limited data gathering of essential history, physical exam, and ancillary studies. A patient with hemoptysis who presents between the two extremes may be managed with variable levels of urgency depending on the overall clinical picture. An astute clinical judgment based on bedside evaluation is important in assessing the urgency with which the clinician must proceed in the management of a patient with hemoptysis.
A patient with a severe underlying lung and heart disease may not tolerate the physiologic and psychological stress associated with lesser amounts of hemoptysis than a patient with no comorbid illnesses. The volume classification of hemoptysis only serves as a marker for the severity of the hemoptysis, without taking into account the associated comorbid issues. Therefore, a rapid global clinical survey of a patient who presents with hemoptysis within the first few minutes of the encounter should be performed. A decision is then made regarding the acuity of the patient, and whether an emergent or urgent intervention in an inpatient setting is indicated, or whether an outpatient evaluation is appropriate.
Patients requiring emergent intervention are those who have active hemoptysis with bright red blood and no sign of slowing down, those with underlying lung diseases limiting their ventilatory reserve, or those with other comorbid illnesses such as coagulopathy, platelet dysfunction, or heart disease. These patients require consideration for intubation for airway protection and ventilation, as well as interventions to stop the bleeding, both temporizing and definitive. Patients requiring an urgent intervention are those whose hemoptysis is intermittent without rapid large-volume expectoration of bright-red blood, especially if other comorbid illnesses exist. As long as the airway is not compromised, a thorough medical evaluation may be undertaken while interventions to stop the bleeding are being pursued.
The evaluation and management of patients with scant hemoptysis or occasional blood-streaked sputum can usually be accomplished in an outpatient setting, and the clinician has the luxury of obtaining a complete medical database without the need for urgent or emergent intervention. Important history to obtain includes the length of time hemoptysis has occurred and the relative estimate of the volume of hemoptysis; the character of hemoptysis (bright-red blood or clots, mixed with purulent-looking sputum or just blood, etc.); the associated problem of the nasal passages, sinuses, or oropharynx as a potential source of the bleeding; symptoms associated with or suggestive of an active infection or malignancy; any underlying cardiopulmonary, renal, or systemic disease; history of smoking; and a baseline premorbid pulmonary function test, whether by objective testing or by functional inference (walking or stair-climbing ability). The physical exam should focus on the overall condition of the patient, the cardiopulmonary status, and any signs that may suggest the presence of an active infection, malignancy, or systemic disease. The initial ancillary studies obtained may include an evaluation of blood and platelet count, renal function, and coagulation studies, in addition to frontal and lateral chest radiographs.
Because bronchitis and bronchiectasis are common diagnoses in hemoptysis, a trial of antibiotics is often prescribed, unless the ancillary studies or chest radiographs suggest another diagnosis. Most patients with normal chest radiographs and ancillary data may not need a bronchoscopy or additional studies. Smokers of more than 40 pack-years and older than the age of 40 years with hemoptysis should be considered for a diagnostic bronchoscopy with airway inspection to rule out an early endobronchial tumor, which may be found in as many as 10% of patients. 2,3 In the setting of normal chest radiographs and bronchoscopy, no further workup is indicated. Chest computed tomography may be obtained to delineate further any abnormalities noted in the radiograph, during bronchoscopy, or from the sign and symptom review.
If an endobronchial tumor is found on bronchoscopy, biopsy specimens should be acquired with caution, because some (such as a carcinoid tumor or Kaposi's sarcoma) may be highly vascular and may bleed substantially on biopsy. The use of epinephrine washes to stop the endobronchial bleeding is of questionable efficacy. One to 2-mL aliquots of 1:20,000 epinephrine solution may be used for this purpose. It is preferable to use electrocautery, laser, or cryotherapy to coagulate the surface of the tumor to prevent further bleeding.
A patient with scant hemoptysis and chest radiographs suggestive of an active granulomatous disease should have the sputum collected for analysis of acid-fast organisms before bronchoscopy. A skin test for latent tuberculous infection should also be performed. An important consideration in the gathering of the medical database is the evaluation for clinical probability of pulmonary thromboembolism as the cause of scant hemoptysis, and the use of appropriate studies to follow. When pulmonary thromboembolic disease is diagnosed in a timely manner, not only can the survival of the patient be altered dramatically, but also the management can be quite different. Although anticoagulation is contraindicated in a patient with hemoptysis in general, it is the treatment of choice in a patient with pulmonary thromboembolic disease.
Patients with a moderate amount of hemoptysis beyond blood-streaked sputum, or those with substantial comorbid cardiopulmonary or hematologic illnesses should be considered for inpatient observation and workup. These patients may need a broad spectrum of management urgency that falls between the extremes of scant hemoptysis and massive hemoptysis. The decision to admit such a patient to the intensive care unit as opposed to a medical ward depends largely on the perceived stability of the patient and the level of intervention needed. It is preferable to err on the side of caution when dealing with a patient with limited cardiopulmonary reserve who is having a moderate amount of hemoptysis. If no impending airway compromise is anticipated, early bronchoscopy with judicious use of sedation is preferable to late bronchoscopy. There is a golden window of opportunity for optimal bronchoscopy in such a patient. An emergent bronchoscopy in a patient with active hemoptysis is often fraught with limited endoscopic visibility because of the presence of blood, clots, and bubbles in the airway that may compromise the localization of the bleeding source. On the other hand, if the clinician waits too long and the bleeding has ceased completely, bronchoscopy would be less likely to reveal the bronchial source of the bleeding. It is the time when a lesser amount of bleeding is still occurring under a controlled situation that bronchoscopy is more likely to be diagnostic.
A judicious use of an antitussive agent is helpful in controlling the hemoptysis. Although limiting the cough may result in less shear force generated inside the airway in a patient with nonmassive hemoptysis, the patient still needs to stay awake to protect the airway, and still needs to be able to expectorate the blood clots within the central airway. It is a matter of achieving a balance between allowing the bleeding site to tamponade itself with blood clots and keeping the more proximal airway (the dead-space) relatively free from blood clots. The use of codeine-based antitussive agents or their synthetic analogs also decreases the patient's anxiety and helps calm the patient. The dose should be titrated just enough for cough suppression without altering the mental status. The patient should be kept NPO in anticipation of possible urgent or emergent bronchoscopy, should the hemoptysis worsen during the period of observation.
In a patient with active massive hemoptysis and impending airway compromise, a limited clinical history and physical exam should be obtained while a frontal chest radiograph, routine blood count with platelet count, coagulation studies, and blood product cross-matching are being obtained. An important part of the assessment is the bedside evaluation of the possible source of bleeding in the oropharynx or the posterior nasal passage. A rapid assessment of prior lung history and premorbid functional state is essential in determining whether the patient may be an operable candidate if lung resection is indicated.
This is not the time to obtain a bedside spirometry. The standard premorbid two-block walk and two-flight stair climbing are adequate in the setting of unknown baseline pulmonary function. If the patient is potentially an operable candidate, then an early courtesy call to a thoracic surgeon may be helpful. An emergent bronchoscopy is set up while the assessment continues. Immediate attention should be given to the adequacy of airway patency, breathing, and the circulatory system. Correcting any known coagulopathy or platelet abnormality is in order, along with volume and red blood cell replacement therapy. Two large-bore peripheral intravenous accesses should be placed in anticipation of active volume resuscitation.
When a patient is able to protect his airway, it is preferable to let him expectorate the blood until bronchoscopy is ready. Keeping the patient in an upright sitting position may minimize his anxiety. If the chest radiograph demonstrates a unilateral lesion that is likely to be the source of the patient's hemoptysis, the patient may be placed in a semirecumbent lateral decubitus position with the side of the lesion down. A patient with massive hemoptysis usually will not tolerate a full lateral decubitus position without sedation, which usually requires intubation.
If the patient is not able maintain a patent airway because of massive blood expectoration or blood clots, emergent intubation should be attempted. Otherwise, it is preferable to wait for the arrival of a bronchoscope before the intubation. When the flexible bronchoscope setup is ready, the patient is sedated and intubated orally with a size 8 to 8.5 tube for a woman, or a size 8.5 to 9 tube for a man. Nasal intubation should be avoided to prevent nasal bleeding that may complicate the clinical picture, and to allow sufficient length of endotracheal tube for mainstem bronchus intubation. Before bronchoscopic intubation, it is important to inspect the subglottic space and the upper trachea for a mass lesion or source of bleeding. After the endotracheal intubation is achieved, bronchoscopic inspection of the entire tracheobronchial tree is performed, preferably with a therapeutic bronchoscope having the largest working channel available.
In an actively bleeding patient, bronchoscopic vision is often very limited. Blood in the airway mixed with ventilated air usually forms bubbles that interfere and distort endoscopic vision. Large blood clots sometimes occupy the airway impairing ventilation, oxygenation, and inspection. Sometimes vision is so limited that the bronchoscopist may have to remove the blood or blood clots using a large (16-French) suction catheter or a cryoprobe to inspect the airway adequately. The availability of a flexible cryoprobe that fits inside the working channel of a bronchoscope is very useful in removing large, fresh blood clots that obstruct the central airway and cannot be otherwise removed by the bronchoscope or a large suction catheter. The bronchoscopist should be on the lookout for endobronchial lesions that may be the source of bleeding. Occasionally, the presence of scattered blood clots may hide a small endobronchial lesion, but a small lesion normally would not be the cause of a massive hemoptysis. It is uncommon to see an endobronchial lesion or mass as the cause of a massive hemoptysis without any antecedent symptoms associated with the lesion. The symptoms may include scant hemoptysis heralding this massive hemoptysis, or symptoms related to airway obstruction. Although blood may originate from a bronchial segment, the entire tracheobronchial tree may be filled with blood and clots. Frequent suctioning is needed to keep the blood from pooling and to clear the field. If a source of bleeding is not readily apparent during bronchoscopic inspection, 5 to 10-mL aliquots of saline washes or 10 to 15-mL lavages in each segmental or subsegmental bronchus may be useful in identifying the source of bleeding. If the lavage fluid return from a bronchial segment is persistently bloody, it is likely that the source of the bleeding has been found. When a unilateral source of bleeding is identified, the patient may be placed in a lateral decubitus position with the bleeding side down.
Sometimes, the sedation and the ensuing cough suppression are enough to stop or slow the bleeding temporarily. In most patients, however, some degree of bleeding continues to occur. Epinephrine washes, cold saline lavage, topical thrombin, or fibrinogen thrombin have been used to control the bleeding with variable levels of success. 4–6
If active bleeding comes from a lesion in a main bronchus, or localization of the bleeding source beyond a main bronchus is not possible, the contralateral main bronchus should be intubated, guided by the bronchoscope. For positioning of the endotracheal tube in the right main bronchus, care must be taken to avoid obstructing the right upper lobe orifice. As long as the cuff of the tube is not directly over the orifice of the right upper lobe or in the bronchus intermedius, the Murphy eye on the right side of the tip of a standard endotracheal tube will allow some level of ventilation to the right upper lobe. This is an important consideration in performing isolated right-lung ventilation in a patient with an underlying lung pathology and limited pulmonary reserve. Such a patient may not be able to oxygenate and ventilate adequately with the right middle and lower lobes only, if the right upper lobe becomes atelectatic from endotracheal tube obstruction. Low ventilation-perfusion areas caused by alveolar filling of inspissated blood in the right lung combined with atelectasis of the right upper lobe may cause severe hypoxemia in a patient with a limited pulmonary reserve.
An alternative method of securing the airway for unilateral tamponade is by using an Arndt endobronchial blocker (AEB; Cook Critical Care, Bloomington, IN, USA;Fig. 1). The AEB is a catheter that has a loop distal to a balloon that allows it to be hooked up to the tip of a bronchoscope for direct placement into a main, lobar, or segmental bronchus to achieve tamponade. In contrast to the placement of an endotracheal tube to the nonbleeding main bronchus, the AEB is positioned in the bleeding bronchus to create a tamponade effect and to prevent spillage of blood into the remaining bronchi. The AEB may be piggybacked onto a small bronchoscope within a large (no. 8.5 or 9) endotracheal tube. It is not possible to accommodate the AEB and a therapeutic bronchoscope or a large suction catheter inside an endotracheal tube. Therefore, it is preferable to pass the AEB outside the endotracheal tube using either a bronchoscope or a laryngoscope. When the AEB is passed into the trachea, the bronchoscope can be passed separately through the endotracheal tube, and then into the distal loop of the AEB, guiding it to its final position.
A small Fogarty catheter or a protected bronchoalveolar lavage catheter with a distal balloon may also be passed inside the working channel of the bronchoscope for segmental or subsegmental bronchial tamponade. A larger Fogarty catheter can be passed outside the endotracheal tube into the trachea, and then guided by a bronchoscope into the bleeding bronchus. It is relatively easy to guide a Fogarty catheter into a main bronchus, but it is more challenging to guide the catheter into a lobar or segmental bronchus.
In my opinion, the double-lumen tube has no role in the management of acute massive hemoptysis today. Not only does it require considerable experience in its placement, the small channels do not allow a therapeutic bronchoscope or a large suction catheter to pass through. With the use of a large endotracheal tube and bronchoscopically guided selective main bronchus intubation, or with the adjunctive use of an endobronchial blocker, the double-lumen tube has nothing to add in the management of massive hemoptysis.
After the bleeding site is identified and the airway is protected, a more definitive therapy is then planned. Whenever possible, a patient with massive hemoptysis caused by a focal lesion should be considered for surgical resection. Similarly, in a patient with recurrent moderate bleeding cause by a focal lung lesion, a surgical resection should also be considered.
Depending on the clinical scenario, selective pulmonary or bronchial arteriography with embolization of the bleeding vessel may be performed as a bridging therapy before surgery or as definitive therapy. For patients with limited pulmonary reserve who are not surgical candidates, arterial embolization is the treatment of choice for control of bleeding that is not caused by a visible endobronchial tumor. Mal et al. 7 recently reported a 77% immediate success rate in stopping hemoptysis with bronchial artery embolization, and 57% in 30 days and 45% after 90 days. Most localized pulmonary bleeding sources are likely to come from branches of the systemic circulation. Although the bronchial arteries are the most common source, other systemic arteries (subclavian, axillary, etc.) may also contribute to the bleeding site. Occasionally one may find a bronchial–pulmonary artery anastomosis or a pulmonary arteriovenous malformation as the source of bleeding. Even if the bleeding source is not identified during bronchoscopy, there are indirect signs of bleeding and abnormal vessels that may be embolized during arteriography, especially if the chest radiographs localize the disease to a focal area that corresponds to the vascular abnormalities. If hemoptysis recurs, a repeat arteriography with embolization may be performed.
The endobronchial balloon should be deflated if control of bleeding is achieved with embolization. Similar to the principles of endotracheal and tracheostomy tube cuff inflation, the least amount of volume and pressure required to seal the bronchial lumen is used in balloon tamponade to prevent mucosal ischemia and future bronchial stricture.
It is possible that the source of bleeding is quite diffuse bilaterally, as seen in diffuse alveolar hemorrhage. In this setting, bronchoalveolar lavage may reveal bloody return in multiple sites and perhaps bilaterally. With diffuse alveolar hemorrhage, no bronchoscopic intervention is useful beyond securing the airway and establishing the diagnosis. These patients require medical therapy that is based on the etiology. It is still important to place a large enough endotracheal tube to be able to suction the blood to prevent central airway obstruction.
Less commonly, one finds a large and highly vascular endotracheal or endobronchial tumor as the cause of the hemoptysis. Consultation with a thoracic surgeon is very helpful, unless the patient's medical condition or the location of the tumor clearly eliminates the option of a surgical intervention. Examples include lesions located in the trachea or proximal main bronchi, or a limited pulmonary function that would not be able to withstand a thoracotomy for lung resection. Angiography with embolization of the tumor blood supply may be useful as a bridging therapy to stop the bleeding while further workup for the appropriateness of surgery is being considered.
An actively bleeding, large tracheal tumor could easily cause total airway obstruction and asphyxiation, and hence requires emergent rigid bronchoscopic intervention, because such a lesion typically would not lend itself to an open surgical resection. While arrangements to transport the patient to an operating room are being made, attempting temporary control of bleeding using the flexible bronchoscope by electrocautery, cryotherapy, or Nd:YAG laser may be helpful, but is usually difficult to accomplish. Small aliquots of 1:20,000 epinephrine may also be used, but is seldom successful in controlling the bleeding. These modes of temporizing therapy, when used, should not interfere with the preparation of the patient to the operating room for rigid bronchoscopy.
The patient should then be placed in a lateral decubitus position with the tumor location down or at random (e.g., left). This maneuver allows the blood to gravitate selectively into the lower lung (e.g., left) while keeping the higher lung (e.g., right) relatively free of blood. Ideally, a small endotracheal tube (no. 6 or smaller) that could be passed into the main bronchus of the higher lung (e.g., right) would allow unilateral ventilation as described earlier. In practice, however, unilateral main bronchus intubation with a small endotracheal tube, even when guided by a very thin bronchoscope when available, over and beyond an actively bleeding high-grade tracheal tumor, would be quite challenging and may traumatize the tumor to bleed even more. An alternative method is to position the patient in a random lateral decubitus position as described, and then pass the therapeutic bronchoscope beyond the obstructing tracheal tumor to the main bronchus of the higher lung. The bronchoscope can be used to remove the blood or secretions that collect inside the bronchus of the higher lung. The rubber seal of the working channel of the bronchoscope can then be removed, and an oxygen catheter may be connected directly to the metal edge of the working channel for direct bronchial gas insufflation (Fig. 2). This maneuver allows gravitational pooling of the blood into the lower lung, while oxygenation of the higher lung is accomplished with 100% oxygen at a variable flow rate, and hopefully will buy some time until the eventual transport of the patient to the operating room. Similarly, if a high-grade obstruction occurs in a main bronchus with active bleeding, placing the ipsilateral side down and intubating the contralateral main bronchus is appropriate for control of the airway until rigid bronchoscopy is ready to be performed.
In centers where the endoscopy suite can accommodate general anesthesia, rigid bronchoscopy can be performed when general anesthesia is administered, without having to move the patient. Although a flexible bronchoscope can be used with laser or electrocautery for control of bleeding and complete removal of an endobronchial or endotracheal mass, it is not the appropriate instrument in a high-grade airway obstruction with active bleeding. A rigid bronchoscope, used by a surgeon or a pulmonologist, should be the instrument of choice for such a patient.
In conclusion, a pulmonologist with basic bronchoscopy skills has a lot to offer in the evaluation and management of a patient with varying levels of hemoptysis. Evaluating and managing a patient with hemoptysis requires a methodical yet flexible approach. An overall gestalt of the level of urgency should be established within the first few minutes of patient evaluation. Massive hemoptysis is a medical emergency that may carry a high mortality rate. It is always safer to err on the side of caution and manage the patient with hemoptysis with a higher level of acuity when the stability of the patient is in doubt. In managing massive hemoptysis, securing the airway with a large-lumen tube is the first priority. When the source of bleeding is localized beyond the trachea, the airway can be protected by contralateral selective mainstem bronchus intubation or ipsilateral balloon tamponade.