Massive Haemoptysis - therapeutic options
Fibre-optic bronchoscopy
No fibre-optic interventions have bee consistently shown to have outcome benefit.
- Flexible bronchoscopy usually first line over rigid as is more readily available and can be used bedside. Rigid has greater suctioning capacity, if the volume of blood obscures the view on flexible bronchoscopy
- Balloon tamponade or application of a bronchial blocker – 4 Fr Fogarty balloon catheter placed into segmental/sub-segmental bronchus that leads to the bleeding site, kept inflated to 24-48 hours. Hypothetical risk of ischaemic mucosal damage and post obstructive pneumonia, but not reported in literature.
- Iced saline lavage – 50mL aliquots at a time. Hypothesised to cause local vasoconstruction but no controlled data showing benefit
- Topical medications –vasoconstrictors (adrenaline 1:20,000 or vasopressin) and local coagulants (thrombin/fibrin)
- Local laser therapy/electrocautery/cryotherapy – more easily
Angiography
Pulmonary circulation consists of low pressure pulmonary arteries (95%) and high pressure bronchial arteries originating from the aorta.
Contrast is injected initially into bronchial arteries (main source in massive haemoptysis).
Pulmonary arteries only investigated if nothing seen on bronchial artery investigation, or if history of AVM or an iatrogenic tear suspected.
Systemic circulation investigated if nothing seen on investigation of the pulmonary circulation.
Anatomical variance of bronchial arteries and non-bronchial systemic collateral arteries can contribute to inadequate embolisation in the setting of a bleed, but despite these anatomical considerations, success rate is 85%.
Limitations/complications
- Anterior spinal artery occlusion (<1% with experienced operator) – risk paraplegia
- Anatomical variability – number and location of bronchial arteries
- Bleeding rate is most often insufficient to visualise extravasation (needs to be >1mL/minute to reliably visualise)
- Findings on angiography can appear similar to those in chronic lung disease (tortuous, hypervascularised).