The pulmonary physician in critical care • Illustrative case 7: Assessment and management of massive haemoptysis
- 1Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne, UK
- 2Department of Respiratory Medicine and Intensive Care, Freeman Hospital, Newcastle upon Tyne, UK
- Correspondence to:
Dr J L Lordan, Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK;
The unpredictable and potentially lethal course of massive haemoptysis requires prompt resuscitation, airway protection, and correction of coagulopathy. Early investigation with bronchoscopy is recommended for localisation and control of bleeding by the application of topical adrenaline, balloon tamponade, or selective lung intubation. There is increasing acceptance of bronchial artery embolisation as the treatment of choice for acute massive haemoptysis not controlled by conservative treatment, when a bronchial artery can be identified as the source of bleeding. Surgical resection remains the treatment of choice for particular conditions where the bleeding site is localised and the patient is fit for lung resection.
Haemoptysis may be the presenting symptom of a number of diseases,1,2 with an associated mortality ranging from 7% to 30%.3–5 Although fewer than 5% of patients presenting with haemoptysis expectorate large volumes of blood, the explosive clinical presentation and the unpredictable course of life threatening haemoptysis demands prompt evaluation and management. We have reviewed the aetiology of massive haemoptysis and alveolar haemorrhage, with particular reference to current diagnostic and therapeutic strategies.
A 69 year old woman was an emergency admission with large volume haemoptysis which did not settle spontaneously. She had previously undergone a left mastectomy for breast carcinoma. Alveolar shadowing was noted in the left mid zone on the chest radiograph, consistent with recent pulmonary haemorrhage (fig 1A). A thoracic computed thoracic (CT) scan confirmed consolidation and volume loss in the left upper lobe and lingula, but also showed a mass anteriorly eroding through the chest wall, consistent with local recurrence of the breast neoplasm (fig 1B). Pulmonary angiography showed no abnormality, but bronchial angiography identified a trunk that supplied a moderate pathological circulation anteriorly in the left upper lobe in the region of the abnormality on the CT scan. The artery was successfully embolised …