Massive Haemoptysis

• Bronchial vascular supply arises from the systemic circulation, which is higher pressure than the pulmonary circulation


• Bronchial arteries supply the bronchi:
• Left lung: two bronchial arteries, arising from the descending thoracic aorta
• Right lung: one bronchial artery, arising from either the thoracic aorta, one of the left bronchial arteries or an intercostal artery


• Bronchial venous drainage occurs via either the pulmonary veins (85%) or bronchial veins (15%)
• Drainage of the bronchial veins is into the
• Left: hemiazygos vein / intercostal vein
• Right: azygos vein

• Iatrogenic vascular injury
• Vasculitis i.e. pulmonary-renal syndromes
• Goodpasture's syndrome (anti-GBM antibodies)
• ANCA-associated vasculitides e.g. GPA, microscopic polyangiitis
• SLE
• Systemic sclerosis
• Arterio-venous malformations
• Tracheo-innominate fistula from cuff of tracheostomy
• Bacterial endocarditis with septic emboli
• Secondary to pulmonary hypertension
• Congenital absence of the pulmonary artery; a rare condition which can present with haemoptysis (20%) although infection (37%) and dyspnoea (40%) are more common features

• Iatrogenic bronchial tree injury e.g. bronchoscopy, interventional pulmonary procedures, blunt/penetrating injury
• Other injury e.g. due to foreign body aspiration
• Bronchiectasis
• Leads to tortuous, hyperplastic bronchial arteries owing to airway dilation
• As the arteries are under systemic blood pressure, they can be a source of bleeding
• Chronic bronchitis

• Tuberculosis, which is the commonest cause worldwide
• Lung abscess, particularly gram negative bacilli e.g. Bacteroides
• Aspergilloma (Aspergillus fumigatus); severe haemorrhage in 25%
• Neoplastic; bronchogenic carcinoma, endobronchial tumours, metastases, sarcoma
• Parasitic

• Coagulopathy e.g. congenital, iatrogenic
• Alveolar haemorrhage is a described complication of amiodarone, phenytoin, methotrexate or nitrofurantoin therapy
• Recreational drugs e.g. cocaine, crack cocaine

• 90% of cases arise from the bronchial circulation
• The precise pathophysiology depends on the aetiology


• In chronic inflammatory conditions, angiogenic growth factors cause bronchial vessel hypertrophy and angiogenesis
• New vessels are friable, thin-walled and liable to rupture as blood is at systemic pressure


• Vascular malformations can either give rise to haemorrhage directly, or predispose to it in inflammatory conditions
• Examples include pulmonary AVM's, or abnormal congenital connections between mediastinal vasculature e.g. bronchial/IMA/subclavian/intercostal arteries

• The main risks here are:
1. Obstructed airway due to blood
2. Pulmonary aspiration of blood
3. Haemodynamic instability from haemorrhage

Massive haemoptysis is an anaesthetic emergency; I would seek senior anaesthetic support as well as making a rapid but thorough assessment of the patient

1. Airway management options (see below)
• If suspected tracheo-innominate fistula from tracheostomy, temporary over-inflation of the cuff can compress the artery against the manubriosternum and buy time


2. Oxygenation and protection against (further) aspiration
• Give oxygen (via nasal specs as haemoptysis may preclude use of facemask)
• Consider investigations to localise source of bleeding:
• CXR: may reveal one lung to be the source although only identify bleeding site in <50% of cases
• Non-contrast CT: may reveal underlying aetiology
• CT angiography: reveals bleeding point in >75% of cases, and locates extra-pulmonary sources of bleeding unlike bronchoscopy
• DSA and fibreoptic bronchoscopy are other options but may be less accurate than CT angiography


3. Essentially management as any major haemorrhage
• IV access x 2
• Activate major haemorrhage protocol
• Bloods including FBC, clotting, group and cross-match, VBG, U&E and LFTs
• Give IV TXA 1g
• Give suitable blood products or crystalloid
• Consider alternate sources of blood e.g. upper GI bleeding, epistaxis

• Uncut single-lumen ETT, which can either be:
• Inserted into the bronchus of the non-bleeding lung under bronchoscopic guidance
• Used as a conduit for insertion of a bronchial blocker into the bronchus of the bleeding lung


• DLT
• Insertion of a left DLT allows isolation of the bleeding lung and selective ventilation of the non-bleeding lung
• May be technically difficult to insert in presence of bleeding
• Lumens aren't wide enough to accommodate a standard size bronchoscope
• Bronchial blocker is another option


• Rigid bronchoscopy
• Benefits from good surgical access for instruments
• Requires alternative anaesthetic (TIVA) and oxygenation techniques
• Cannot reach bleeding distal to the main bronchi

• Treat the underlying cause e.g. antibiotics, steroids for vsculitis


• Tamponade e.g. with a bronchial blocker, although this risks mucosal oedema


• Nebulised TXA or adrenaline


• Lavage with ice-cold saline: repeat instillation of 50ml ice-cold saline into the affected bronchus will cause vasoconstriction


• Injection of vasopressor e.g. adrenaline 1:20,000 via flexible bronchoscope into bleeding site


• Rigid bronchoscopy; used to facilitate LASER, diathermy or cryotherapy of the bleeding point, or other interventions such as stents, silicone plugs or other sealants


• IR
• Embolisation of the bronchial vessels if angiography demonstrates bronchial artery bleeding
• Collateral supply from other vessels often makes this unsuccessful


• Surgical management with lobectomy or pneumonectomy is the last option and is associated with a high (34%) mortality