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814
REVIEW SERIES
Thorax 2003;58:814–819
The unpredictable and potentially lethal course of diameter, fig 2). The internal mammary artery
massive haemoptysis requires prompt resuscitation, was also catheterised and a pathological circula-
tion was noted that was occluded using platinum
airway protection, and correction of coagulopathy. coils (fig 1A) and PVA granules, with no
Early investigation with bronchoscopy is recommended complications and no recurrence of haemoptysis.
for localisation and control of bleeding by the
application of topical adrenaline, balloon tamponade, DEFINITION
or selective lung intubation. There is increasing Although there is no generally accepted definition
acceptance of bronchial artery embolisation as the of the volume of blood that constitutes a massive
haemoptysis, studies have quoted volumes rang-
treatment of choice for acute massive haemoptysis not ing from 100 ml up to or more than 1000 ml per
controlled by conservative treatment, when a bronchial day.2 As the anatomical dead space of the major
artery can be identified as the source of bleeding. airways is 100–200 ml, a more relevant definition
of massive haemoptysis is the volume that is life
Surgical resection remains the treatment of choice for threatening by virtue of airway obstruction or
particular conditions where the bleeding site is localised blood loss.5 6
and the patient is fit for lung resection.
.......................................................................... AETIOLOGY
It is important to establish that the lung is the
H
aemoptysis may be the presenting symp- source of bleeding, in part by excluding the
tom of a number of diseases,1 2 with an nasopharynx or gastrointestinal tract. The most
associated mortality ranging from 7% to common causes of massive haemoptysis are listed
30%.3–5 Although fewer than 5% of patients in box 1. Haemoptysis originates from the
presenting with haemoptysis expectorate large bronchial and pulmonary circulation in 90% and
volumes of blood, the explosive clinical presenta- 5% of cases, respectively.7 Bleeding from the
tion and the unpredictable course of life threaten- bronchial arteries has the propensity to cause
ing haemoptysis demands prompt evaluation and massive haemoptysis as it is a circulation at
management. We have reviewed the aetiology of systemic pressure. Alveolar haemorrhage is a rec-
massive haemoptysis and alveolar haemorrhage, ognised cause of haemoptysis, but rarely causes
with particular reference to current diagnostic massive bleeding as the alveoli have the capacity
and therapeutic strategies. to accommodate a large volume of blood.8 A more
common presentation is mild haemoptysis, pul-
monary infiltrates, and anaemia.2
CASE HISTORY Chronic inflammatory conditions (including
A 69 year old woman was an emergency bronchiectasis, tuberculosis, lung abscess) and
admission with large volume haemoptysis which lung malignancies are the most common causes
did not settle spontaneously. She had previously of massive haemoptysis.9 10 Similarly, bleeding
undergone a left mastectomy for breast carci- may occur from a mycetoma in the presence of
noma. Alveolar shadowing was noted in the left cavitating lung disease.11 12 The concurrent devel-
mid zone on the chest radiograph, consistent with opment of haemoptysis and menstruation points
recent pulmonary haemorrhage (fig 1A). A to a diagnosis of catamenial haemoptysis. The
thoracic computed thoracic (CT) scan confirmed presence of haemoptysis and spontaneous pneu-
consolidation and volume loss in the left upper mothorax in a woman of childbearing age with
See end of article for lobe and lingula, but also showed a mass diffuse interstitial abnormalities on the chest
authors’ affiliations anteriorly eroding through the chest wall, consist- radiograph should raise the suspicion of
....................... ent with local recurrence of the breast neoplasm lymphangioleiomyomatosis.16
Correspondence to: (fig 1B). Pulmonary angiography showed no The presence of a saddle nose, rhinitis, or
Dr J L Lordan, Department abnormality, but bronchial angiography identi- perforated nasal septum may suggest a diagnosis
of Respiratory Medicine, fied a trunk that supplied a moderate pathological of Wegener’s granulomatosis.17 Features of Beh-
Freeman Hospital, circulation anteriorly in the left upper lobe in the cet’s disease include oral or genital ulceration,
Newcastle upon Tyne
NE7 7DN, UK;
region of the abnormality on the CT scan. The uveitis, cutaneous nodules, and pulmonary artery
jll1@doctors.org.uk artery was successfully embolised using polyvinyl aneurysm which is associated with a 30% 2 year
....................... alcohol (PVA) foam granules (500–700 µm in mortality rate.18 Although haematuria may be
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DIAGNOSTIC PROCEDURES
Sputum should be sent for microbiological investigation,
including staining and culture for mycobacteria, and cytologi-
cal examination if the patient is a smoker and over 40 years of
age. Chest radiography may help to identify causative lesions
or infiltrates resulting from pulmonary haemorrhage, but fails
to localise the lesion in 20–46% of patients with
haemoptysis.19 A CT scan may show small bronchial carcino-
mas or localised bronchiectasis.13 20 21 The use of contrast may
help to identify vascular abnormalities such as arteriovenous
malformations or aneurysms.14 22 Despite all investigative pro-
cedures, the aetiology of haemoptysis is unknown in up to
5–10% of patients.7
Right Left
Abnormal circulation
Embolised abnormal
left circulation
Figure 2 Use of selective bronchial artery embolisation to control massive haemoptysis. (A) Bronchial angiogram showing common trunk and
left sided abnormal circulation pre-embolisation, and (B) post-embolisation angiogram showing the left bronchial artery and successful
embolisation of abnormal vessels.
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Massive haemoptysis
Investigations Resuscitation
FBC, U&Es, COAG, Oxygen supplementation
ABG, CXR, Correct any coagulopathy
group & crossmatch Consider tranexamic acid
*Admit to HDU/ITU
Respiratory consult
Neodymium-yttrium-aluminium-garnet (Nd-YAG) laser prit vessel with the laser beam can be difficult in the presence
photocoagulation has been used with some success in the of ongoing bleeding.
management of massive haemorrhage associated with directly
Bronchial artery embolisation (BAE)
visualised endobronchial lesions.30 However, targeting the cul-
This was first reported by Remy and colleagues in 197331 and
is increasingly used in the management of life threatening
Right sided
airway filled Blood
with blood
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These include:
References This article cites 41 articles, 10 of which can be accessed free at:
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Notes