pulmonary disorders
Hemoptysis
Treatment of Hemoptysis
Initial treatment of massive hemoptysis has two objectives: Prevent aspiration of blood into the uninvolved lung (which can cause asphyxiation) Prevent exsanguination due to ongoing bleeding It can be difficult to protect the uninvolved lung because it is often initially unclear which side is bleeding. Once the bleeding side is identified, strategies include positioning the patient with the bleeding lung in a dependent position and selectively intubating the uninvolved lung and/or obstructing the bronchus going to the bleeding lung. Prevention of exsanguination involves reversal of any bleeding diathesis and direct efforts to stop the bleeding. Clotting deficiencies can be reversed with fresh frozen plasma and factor-specific or platelet transfusions.Desmopressinis used to reverse platelet dysfunction associated with uremia and kidney disease.Tranexamic acidis an antifibrinolytic medication being increasingly used to promote hemostasis. Laser therapy, cauterization, or direct injection withepinephrineorvasopressincan be done bronchoscopically. Massive hemoptysis is one of the few indications for rigid (as opposed to flexible) Bronchoscopy , which provides control of the airway, allows for a larger field of view than flexible bronchoscopy, allows better suctioning, and is more suited to therapeutic interventions, such as laser therapy. Embolization via bronchial artery angiography is the preferred method with which to stop massive hemoptysis, with reported success rates of up to 90% ( Treatment references ). Emergency surgery is indicated for massive hemoptysis not controlled by rigid bronchoscopy or embolization and is generally considered a last resort. Once a diagnosis is made, further treatment is directed at the cause ( Treatment references ). Treatment of minor hemoptysis is directed at the cause. Early resection may be indicated for bronchial adenoma or carcinoma. Broncholithiasis (erosion of a calcified lymph node into an adjacent bronchus) may require pulmonary resection if the stone cannot be removed via rigid bronchoscopy. Bleeding secondary to Heart Failure (HF) or Bleeding from a pulmonary embolism is rarely massive and almost always stops spontaneously. If emboli recur and bleeding persists, anticoagulation may be contraindicated, and placement of an inferior vena cava filter is the treatment of choice. Because bleeding from bronchiectatic areas usually results from infection, treatment of the infection with appropriate antibiotics and postural drainage is essential. are being increasingly used and studied in minor hemoptysis ( Treatment references ). 1.Mal H, Rullon I, Mellot F, et al: Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis.Chest150 (4): 996–1001, 1999. doi: 10.1378/chest.115.4.996 2.Lordan JL, Gascoigne A, Corris PA: The pulmonary physician in critical care. Illustrative case 7: Assessment and management of massive haemoptysis.Thorax58: 814–819, 2003. doi: 10.1136/thorax.58.9.814 3.Jean-Baptiste E: Clinical assessment and management of massive hemoptysis.Critical Care Medicine28(5): 1642–1647, 2000. doi: 10.1097/00003246-200005000-00066 4.Prutsky G, Domercq JP, Salazar CA, et al: Antifibrinolytic therapy to reduce haemoptysis from any cause.Cochrane Database Syst Rev11(11):CD008711, 2016. doi: 10.1002/14651858.CD008711.pub3 