This document summarizes the presentation of a 32-year-old patient with a history of acute lymphoblastic leukemia and bone marrow transplant who presented with hemoptysis. The patient was initially treated for graft-versus-host disease and neutropenic fever. Imaging showed worsening pulmonary nodules concerning for fungal infection. The patient later developed massive hemoptysis requiring intubation and attempts at bronchial artery embolization, but continued bleeding led to withdrawal of care. The document reviews definitions of massive hemoptysis, etiologies, diagnostic evaluation including CT and bronchoscopy, and initial management approaches for controlling bleeding.

1. Critical Care Conference
Gagan Kumar MD

2. HPI
• 32yo with ALL s/p BMT 6/23/10 with problems of GVHD
and disease relapse
• 10/22/2010: presented with intermittent diarrhea x 3 weeks
and fever up to 100.6f.
• Treated for gut/liver GVHD
• Started on cefepime + Vanco for neutropenic fever. Blood
culture: staph epidermidis

3. PMH
•
•
•
•
•
•
•
Had CT of the chest from 5/10/10 showed nodular opacities
Underwent a Right VATS on 5/17/10 which was later positive for
aspergillus
Started on caspofungin
Repeat CT scan 7/19/10 shows improvement
Repeated CT chest 11/18 with new onset of cough. CT shows new soft
tissue nodule in the left lower lobe and increased nodule in the right
upper lobe concerning for fungal infection.
Skin lesions suggestive of Aspergillus (11/20),
started Voriconazole + Caspofungin

4. Hospital course
• 11/22/2010 – mild hemoptysis in morning which
progressed over the course of day.
• Patient transferred to MICU in evening.
• CXR was done which showed patchy R lung opacities.
• CT chest 2 days prior showed: new soft tissue density
nodularity in superior segment of LLL and medial basal
RLL. Increased size in soft tissue density in RUL.

5. Hospital course
• One hour later in MICU, patient became tachypneic and
hypoxic.
• Patient was intubated – tracheal intubation and
bronchoscopy was performed. Blood was found in right
mainstem. This corresponded with increased infiltrates on
right side.
• The ET tube was slided over bronchoscope to left
mainstem bronchus to prevent flooding of left lungs.
• She was transfused 2 units blood and platelets.

6. Labs

7. Hospital course
•
This somewhat temporized the hypoxia but still it was difficult to
ventilate her with single lung.
•
Her Pox remained ~ 70-80s
•
We henceforth planned to put in two channeled endotracheal tube to
isolate each lung and ventilate them separately.
•
This helped her oxygenation but she started becoming hypotensive.
She was resuscitated with IV fluids and blood products.
Norepinephrine drip was started.

8. Hospital course
• Meanwhile IR was consulted for embolization.
• The bleeder could not be localized by the IR.
– severe vasospasm or occlusion of
the right bronchial artery origin occurred on attempted
recatheterization of the bronchial artery
• Meanwhile, patient continued to have intermittent
hemoptysis and her Pox were in 60s to 70s.
• Her blood pressures continued to drop and her BP did not
respond to fluids, blood transfusion and norepinephrine.
• The family withdrew care.

9. Massive hemoptysis
No clear consensus on its precise
definition

10. Definition
• Major hemoptysis ( > 200 ml/24 h)
• Severe hemoptysis
– > 150 ml/12 h [Gracia et al.]
– > 400 ml/24 h [Khalil et al.]
• Exsanguinating hemoptysis
– > 1,000 ml total or > 150 ml/h [Garzon et al.]
• Life threatening
– rate of at least 200 ml/h in normal or nearly normal lung function
– 50 ml/h in a patient with chronic respiratory failure
– more than 2 episodes of moderate hemoptysis (at least 30 ml)
occurred within 24 h in spite of the administration of intravenous
vasopressin

11. • ‘Magnitude-of-effect’ definition of massive
Magnitude-of-effect
hemoptysis
– Airway obstruction and hemodynamic
instability
•
•
•
•
requiring transfusion
hospitalization
intubation
causing aspiration and airway obstruction
• hypoxemia (PaO2< 60 mm Hg)
• death

12. Sources of Bleeding of massive hemoptysis?
• High Pressure:
– Bronchial circulation (90%)
– Aorta (aortobronchial fistula, ruptured aortic
aneurysm) or nonbronchial systemic circulation
(intercostal arteries, coronary arteries, thoracic
arteries subclavian arteries and upper and
inferior phrenic arteries) - (5%)
• Low pressure:
– Pulmonary vessels (5%)

13. The
bronchial
arteries
originate
from
the
descending Aorta : T5–T6
level
In chronic inflammatory or infectious
lung diseases, many alterations in
vascular anatomy may occur
The most common pattern
(almost 40% of patients) is a
single right bronchial artery
with 2 left bronchial arteries
arising at the T5–T6 level.
In 5% of patients, a
spinal artery
originates from a
bronchial artery !!
http://www.instantanatomy.net/thorax/vessels/abronchial.htm

14. Pulmonary
Infectious
Bronchiectasis
Tuberculosis
Chronic bronchitis
Necrotizing pneumonia and lung abscess
Fungal infections (including mycetoma)
Alveolar hemorrhage
(Klebsiella pneumoniae, Pseudomonas aeruginosa,
Staphylococcus aureus, Streptococcus pneumoniae,
other Streptococcus spp. and Actinomyces spp.)
Vascular
Bacterial endocarditis with septic emboli
Parasitic (paragonimiasis, hydatid cyst)
Pulmonary artery aneurysm
(Rasmussen aneurysm, mycotic, arteritis)
Bronchial artery aneurysm
Miscellaneous
Pulmonary infarct (embolism)
Pulmonary hypertension
Congenital cardiac or pulmonary vascular
malformations
Airway-vascular fistula
Arteriovenous malformations
Mitral stenosis
Left-ventricular failure
Endometriosis
Lymphangioleiomatosis
Broncholithiasis
Cryptogenic
Etiology
Neoplastic
Sarcoma
Lung transplantation
Crack cocaine
Vasculitis
Bronchogenic carcinoma
Endobronchial tumors
(carcinoid, adenoid cystic carcinoma)
Pulmonary metastases
Foreign body aspiration
Wegener’s granulomatosis
Coagulopathy
Platelet disorders
Goodpasture’s syndrome
Behcet’s disease
Systemic lupus erythematosus
Trauma
Pulmonology procedures (dilation, metallic stent placement, high-dose brachytherapy)
Catheter-induced PA rupture
Trans-tracheal procedures

15. Etiology
•
Despite extensive diagnostic workup, cryptogenic massive
hemoptysis has been reported in 11– 19% of cases in the recent
literature
Respiration 2010;80:38–58

16. Rasmussen's Aneurysm
N Engl J Med 2006; 355:e17

17. Hughes-Stovin syndrome
• Autoimmune disorder of unknown cause that is characterized
by
the
combination
of
multiple pulmonary artery aneurysms and deep vein thrombosis
Circulation. 2003;108:e156

18. Life-threatening massive hemoptysis
• 5 to 15% across studies
– Lung cancer:
• 20% had hemoptysis at some time
• Terminal event in 3%
– Cystic fibrosis:
• 4% had massive hemoptysis

19. • Mortality has been shown to be mainly
related to the rate of bleeding :
– Crocco et al.
• 71% in patients who lost > 600 ml of blood in 4 h
• 22% in patients with > 600 ml within 4–16 h
• 5% in those with 600 ml of hemoptysis within 16–48 h.
– Coery et al.
• 58% in patients who lost >1,000 ml of blood in 24
h
• 9% in those with bleeding rates <1,000 ml/24 h.
Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med 1968;121: 495–498.

20. Prognostic factors ?
•
•
•
•
•
Bleeding rate of at least 1,000 ml within a 24-hour period*
Aspiration of blood in the contralateral lung*
Massive bleeding requiring single-lung ventilation*
Bronchogenic carcinoma as an underlying etiology*
Recurrent bleeding following bronchial artery
embolization (BAE)^
– residual mild bleeding beyond the first week after BAE
– blood transfusion before the procedure
– diagnosis of aspergilloma as the underlying etiology
^Int J Tuberc Lung Dis 2009;13: 875–880.
*Am J Med Sci 1987; 294:301–309

21. Diagnosis

22. Initial approach
• Must r/o non-pulmonary causes– upper
airway or gastrointestinal tract
• lungs as the primary source of bleeding
– Alkaline pH,
– foaminess,
– presence of pus

23. Initial approach
• How sick is the patient?
– Patients with rapid bleeding or decompensation need
ACLS first and control of their bleeding.
• Secondary goals
– the site and cause of the bleeding
– Is the patient is a surgical candidate.

24. History
• Prior lung, cardiac, or renal disease?
• History of cigarette smoking?
• Prior hemoptysis, other pulmonary symptoms, or
infectious symptoms?
• Family history of hemoptysis or brain aneurysms
(suggesting hereditary hemorrhagic telangiectasia)?
• Exposure to asbestos?
• Patient's travel history?
• History of bleeding disorders or use of antiplatelet or
anticoagulants?
• History of upper airway or upper gastrointestinal
complaints or diseases?

25. Examination
• Telangiectasias -- hereditary hemorrhagic telangiectasia.
• Skin rash -- vasculitis, systemic lupus erythematosus, fat
embolism, or infective endocarditis.
• Splinter hemorrhages -- endocarditis or vasculitis.
• Clubbing is nonspecific, since it can occur in many chronic
lung diseases.
• Audible chest bruit or murmur that increases with
inspiration -- large pulmonary AV malformations .
• Cardiac murmurs -- congenital heart disease, endocarditis
with septic emboli, or mitral stenosis.
• Legs should be examined carefully for possible deep
venous thrombi.

26. CT Scan
• CT is much more efficient than bronchoscopy for
determining the cause of bleeding (60–77 vs. 2.5–
8%)*
• Informative to guide the approach to bronchial
artery embolization
• Might provide prognostic information.
• Signs of PA bleeding consisted of the following:
– PA pseudoaneurysm/ aneurysm
– Presence of a PA in the inner wall of a cavitary lesion
*Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or
massive hemoptysis? AJR Am J Roentgenol 2002; 179: 1217–1224.

27. • Limitations.
– Unstable patients
– Patients with active bleeding requiring
endobronchial management
– Patients with bilateral lung abnormalities in
whom radiographic bleeding localization might
be challenging

28. Fiber-optic bronchoscopy
• FOB identifies the site of bleeding in 73–93% of episodes
of massive bleeding but is significantly lower in cases of
mild or moderate hemoptysis*
• Limitation
– Massive, life-threatening hemoptysis
– Rigid bronchoscopy is more efficient at
•
•
•
•
safeguarding airway patency
preserving ventilation
allowing better clearance of the airways & improving visualization
flexible fiber-optic bronchoscope can be introduced through the rigid
scope as it provides easier access to the upper lobes and peripheral
bronchi, thus allowing optimal exploration of the bronchial tree
*Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J
Roentgenol 2001; 177: 861–867.

29. Management

30. Initial Steps
• Protection of the airways.
• Volume resuscitation.
• Lateral decubitus position, with the
bleeding side down.
• Reverse coagulation disorders
• Transfer to an intensive care unit.
• Interventional radiology +/- CT
Surgery Consult

31. Protection of non-bleeding lung
• Unilateral intubation
– NOT advisable to selectively intubate the right main
bronchus in case of bleeding originating from the left
lung. [Since you can block opening of RUL]
• Use of balloon catheter:
– Tracheal intubation  followed by insertion of a
balloon catheter besides the endotracheal tube through
the vocal cords, with subsequent introduction into the
left main bronchus under bronchoscopic visualization.
• Placement of a double lumen ETT

32. Double-lumen intubation
http://www.youtube.com/watch?v=J-UnmZj7ylg

33. Airway
• Urgent rigid bronchoscopy should be
attempted (if available)
• Intubated with a large-caliber endotracheal
tube (size 8 or more)
• FOB - to suction blood clots and secretions
& help localization

34. Rigid bronchoscopy
Presence
of
an
interventional
pulmonologist on staff was associated
with increased availability of advanced
procedural training, including rigid
bronchoscopy-related skills.
However, only 41% of the training
programs
which
offered
rigid
bronchoscopy
procedures
allowed
fellows to reach the targeted number (20
procedures) to obtain competency*.
Availability of an operating theater, an
anesthesiologist and good and effective
collaboration with thoracic surgeons are
necessary as well
*Pastis NJ, Nietert PJ, Silvestri GA: Variation in training for interventional pulmonary procedures among US
pulmonary/critical care fellowships: a survey of fellowship directors. Chest 2005; 127: 1614–1621.

35. Cold-Saline Lavage
• Normal saline at 4 ° C in 50-ml aliquots
• Complications:
– sinus bradycardia

36. Topical Vasoconstrictive Agents
• Can be effective in mild to moderate hemoptysis
• Not useful for massive bleeding : because the drug
is diluted and washed away
• Topical epinephrine : 1: 20,000
• Complications:
– Hypertension
– tachyarrythmias
• Topical Terlipressin/ Ornipressin (similar efficacy
lesser side effects)

37. Tranexamic Acid
• Antifibrinolytic drug
• Via the oral or intravenous route ( can be
used in conjunction with bronchial artery
embolization)
– Literature is mostly limited to cystic fibrosis
patients
• Endobronchial instillation* :500–1,000 mg.
– 2 cases of endobronchial tumors
*Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M: Pulmonary hemorrhage:a novel mode of
therapy. Respir Med 2009;103: 1196–1200.

38. Fibrinogen/Thrombin
• Local application of cold saline, epinephrine, or
collapse of the bleeding bronchus through
continuous suction  drying of the airway
thereafter with oxygen  the fibrinogen-thrombin
instilled through a catheter within an FOB
• Factor XIII and Aprotinin were added to the
mixture for better stabilization of the fibrin clot
• Controlled bleeding in 11 patients who had C/I or
unavailability of BAE.
de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F: Use of endoscopic fibrinogen– thrombin
in the treatment of severe hemoptysis. Respir Med 2003; 97: 790–795.

39. Balloon Tamponade
• Fogarty balloon catheter
: through a flexible fiberoptic bronchoscope
• Freitag: double lumen.
One for balloon and other
to instill cold saline or
vasoconstrictive agents.
– deflated for a few minutes 3
times a day, in order to
preserve mucosal viability
and to check for bleeding
recurrence.
– Complications:
• lobar pneumonia
• hoarseness

40. Other endobronchial methods
• Endobronchial Stent
Tamponade : self-expanding
airway stents
• Endobronchial Airway
Blockade :
– Silicone Spigot
– Oxidized regenerated cellulose
mesh, a sterile kitted fabric
– Biocompatible Glue (n-butyl
cyanoacrylate): solidifies on
contact with humidity

41. Coagulation of bleeding vessel
• Argon Plasma Coagulation:
– blood is a good conductor  effective dessication of a bleeding
bronchus can be performed
– Once dessication of the targeted surface is achieved, it becomes
less electrically conductive, thus preventing deeper penetration
– Better than YAG: allows homogeneous tissue dessication & can
reach around anatomic corners since flexible probe.
– Limitations:
• used only when the source of bleeding is within the reach of the
bronchoscope
• Cryotherapy : vasoconstriction and formation of
microthrombi in venules and capillaries
– inoperable endoluminal malignancies

42. Bronchial Artery Embolization
• Remy et al. in 1973
– 49 patients during active hemoptysis
– Controlled in 41
– 6 with recurrent bleed in 2-7 months
• Overall success in literature: 57-100%
• Overall bleeding recurrence after BAE : 10 - 29% of
patients at 1-month follow-up

43. Persistent bleeding after BAE
• Incomplete embolization of the bronchial
vessels,
• Recannalization of the embolized arteries,
• Presence of nonbronchial systemic arteries,
• Development of collateral circulation
• Bleeding of PA origin

44. Complications
•
•
•
•
Pyrexia
Chest pain
Transient dysphagia
Groin hematoma Subintimal dissection or
perforation of arteries by the guidewire
• Transient or sometimes permanent
neurological deficits

45. Surgery
• Emergency surgery: mortality 30%
• C/I
–
–
–
–
poor functional status,
moderate to severe lung function impairment,
Bilateral pulmonary disease
Other comorbidities
• Indication:
–
–
–
–
–
–
–
repeated recurrences of hemoptysis despite BAE
Necrotizing lung infections such as mycetomas
majority of patients with aspergilloma
PA hemorrhage in the context of resectable lung tumors
Diffuse and complex arteriovenous malformations
Iatrogenic PA rupture
chest trauma

46. Respiration 2010;80:38–58

47. Thank you