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Hemopytis is expectorated blood from the tracheobronchial tree or the pulmonary parenchyma. Various volume of blood per day have been suggested to qualify for the term massive hemoptysis. But the term massive hemoptysis generally indicates expectoration of blood that results in hemodynamic compromise. The airway obstruction, blood loss and hypotension that accompany massive hemoptysis are life threatening. Massive hemoptysis is a critical illness with significant mortality. The mortality depends on the volume of blood expectorated and the underlying lung pathology. The mortality is highest with bleed greater than 1000ml/day and with malignancy.

Multidisciplinary Team
Massive hemoptysis should ideally be managed in ICU setting of a tertiary care hospital by a team of interventional pulmonologist, intensivist, interventional radiologist and thoracic surgeon.  Hematologist and nephrologist input may be sought in case of coagulopathies and goodpasture’s syndrome with renal involvement respectively.

Principles of Mangement
Stabilize hemodynamics
Determining the side of hemoptysis and lung segment
Determining the cause of hemoptysis – underlying lung pathology
Strategies to stop bleeding

Source of Bleeding
Bronchial arteries – 90 percent
Non bronchial systemic arteries – 5 percent
Pulmonary arteries – 5 percent
Since bronchial arteries receive blood supply from the systemic arteries, blood pressure in the bronchial arteries is high and this predisposes to excessive bleeding.

Commonest cause of massive hemoptysis

1. Tuberculosis
2. Bronchial carcinoma
3. Bronchiectasis
4. Aspergilloma
5. Acute and Chronic Bronchitis
6. Pneumonia
7. Lung abscess
8. Cystic Fibrosis
9. Iatrogenic – endobroncial biopsies from vascular tumours, swan ganz catheterization etc
10. Alveolar haemorrhage due to Goodpasture’s syndrome and other vasculitis

General measures

1. Preliminary history including previous lung disease, smoking history, previous episodes of hemoptysis, anticoagulant use, history of tuberculosis, cardiac history, renal disease as in Goodpasture’s syndrome, oral contraceptive use (risk of embolism)  etc
2. Rule out other causes of bleeding from nasopharynx and gastrointestinal tract. Bleeding from laryngeal tumours like fibroangiomatous polyp and laryngeal granuloma can also mimic hemoptysis.
3. Localization of the side - Patients can sometimes point to the side as they may have a vague gurgling feeling at the side of hemoptysis.
4. The patient is positioned in lateral position so the bleeding lung is in the dependent position to prevent aspiration to the non-bleeding lung.

Stabilize hemodynamics

1. Intravenous fluids
2. Blood and packed red blood cells if needed
3. Secure the airway with wide bore (8 size and above) endotracheal tube or double lumen ET tube if needed. Double lumen ET tube or selective main bronchi intubation can be done to isolate the bleeding lung and protect the uninvolved lung.
4. Supplemental oxygen to maintain the saturation
5. Blood products/Vitamin K or procoagulant factors if the patient was on any anti-coagulants previously
6. Intravenous antibiotics if infection is suspected.
7. The specific management in each case depends on the cause of the hemoptysis and the expertise available at the hospital.

Initial investigation
Chest X ray
Hemoglobin / Complete blood count
Blood grouping and cross matching
Coagulation profile

Later investigations
CT-Chest to look for underlying pathology
Bronchoscopy for localizing the site of bleed
CT- angiography
Sputum cytology,
Renal functions/urinanalysis (pulmonary-renal syndrome)
Echocardiogram

Conservative Medical Management
Conservative medical approach is the initial treatment of choice for hemoptysis due to coagulation abnormalities. The coagulation parameter is corrected by administering blood products and procoagulant factors.  In hemoptysis due to alveolar haemorrhage as in Goodpasture’s disease treatment with steroids, cyclophosphamide and plasmapheresis is commenced and the alveolar haemorrhage usually resolves within a few days. Stool softeners should be given to prevent the patient from exerting himself. Cough suppressants like codeine preparations may be given to prevent cough but it may interfere with the clearance of secretion and clots in the airway.

Bronchoscopy
Bronchoscopy should be ideally done as soon as possible in the first 24 hours if condition permits. If the bleeding is heavy, the field would become obscured with blood and it is difficult to gain useful information. The bleeding from lung should be differentiated from the blood that may trickle down due to the cricothyroid injection given prior to the bronchoscopy. Both flexible and rigid bronchoscopy have unique applications in hemoptysis and the choice of either depends on the operator preference and underlying cause of hemoptysis. While the rigid bronchoscopy with larger channel helps in therapeutic procedures and removing clots, flexible bronchoscopy is needed to visualize bleeding from distal airways which cannot be visualized with the rigid instrument. The role of the bronchoscopy is as follows

1. To establish the side  and the location (lung segment) of the bleed
2. To identify the underlying lung pathology (eg. Endobronchial tumour)
3. Bronchoscopic measures like instillation of cold saline at 4 degree celsius, diluted epinephrine, thrombin, thrombin-fibrinogen can be used.
4. If the bleeding is iatrogenic due to endobronchial biopsy, the bronchoscope can be wedged against the bleeding spot.
5. Success with laser photocoagulation and electrocautery for bleeding from endobronchial lesions have been reported
6. Hemostatic sealant glue like n-butyl cyanoacrylate can be instilled endobronchially
7. Fogarty’s catheter can be introduced through flexible bronchoscopy and ballon dilated to create temporary tamponade.
8. Rigid bronchoscopy can be done if blood clots are blocking the major airways. Clotting of even 150 ml of blood in the proximal airways can block the airflow and result in significant hypoxia.

Bronchial Artery Embolization
Bronchial artery embolization is a very effective procedure with immediate success rates above 90 percent though recurrence of bleeding can occur later. In BAE polyvinyl alcholol particles or other material are used to embolize suspected abnormal bronchial artery branches. The following angiographic findings generally warrant embolization

1) Hypervascularity
2) Tortuous and enlarged bronchial arteries
3) Shunting into pulmonary artery or vein
4) Parenchymal staining
5) Aneurysm
6) Extravasation of dye into the airway

The complications include embolization of anterior spinal artery resulting in paraplegia, contrast allergies, post embolization syndrome comprising chest pain and fever, bronchoesophageal fistula and transient neurological symptoms. Rarely the embolic particles can dislodge and block other vital systemic vessels and cases of stroke, esophageal infarction, necrosis of wall of aorta have been reported. But with the super selective techniques and the use of appropriate particle sizes and proper identification of the anterior spinal artery, the risks of adverse events are lower. If the bronchial arteries have well developed collaterals as it may occur in chronic inflammatory conditions like tuberculosis, bronchiectasis and cystic fibrosis, it may pose a difficulty in bronchial artery embolization. The contraindication for bronchial artery embolization include congenital pulmonary artery stenosis where the bronchial circulation provide vital parenchymal perfusion and other contraindications for angiography such as contrast allergy, renal failure etc.

Surgery
Pulmonary resection (segmentectomy, lobectomy, wedge resection, pneumonectomy) was earlier considered the first option for massive hemoptysis but with the availability of bronchial artery embolization and other non-surgical options, surgery is considered only in cases where the other modalities have failed. Bronchial artery embolization by delaying the surgery gives valuable time to stabilize hemodynamics and prepare the patient prior to surgery. The post surgery mortality and morbidity in high when done in an emergency setting. If bronchial artery embolization fails, surgery (lobectomy. wedge resection, peumonectomy) is attempted only if the bleeding is localized, the bleeding source correctly identified by bronchoscopy or CT-Chest and the patient has sufficient pulmonary reserve to survive post operatively. In hemoptysis due to certain conditions like thoracic vascular injury, leaking aortic aneurysm, arteriovenous malformations vascular surgery is the primary modality of management.

Others
Radiotherapy has been reported to be useful in stopping bleeding from aspergilloma and bronchial tumours. Antifungal drugs instilled inside the cavity have been found to be useful in recurrent hemoptysis due to aspergilloma. Cavernostomy is one of the older procedures used for bleeding from cavitary lesions.

Further Reading

Causes of Hemoptysis

Bronchoscopy

References
http://www.ncbi.nlm.nih.gov/pubmed/10834728
http://ats.ctsnetjournals.org/cgi/content/abstract/87/3/849
http://ajrccm.atsjournals.org/cgi/content/abstract/157/6/1951
http://www.ncbi.nlm.nih.gov/pubmed/21331108
http://www.ncbi.nlm.nih.gov/pubmed/21326520
http://www.ncbi.nlm.nih.gov/pubmed/17332480
http://www.ncbi.nlm.nih.gov/pubmed/11083697
http://www.essbronchology.com/journal/june_2008/abstrcts/7-Sayed_Oraby.html