Massive hemoptysis
Common definition: >300 mL in 24h, >50 mL in 1h
Patients die from asphyxia not acute anemia
Bronchial hemorrhage etiologies: CF, TB, Sarcoid, Wegener’s, recurrent pneumonia or abscess
Absolute: Non-bronchial artery source
PA hemorrhage etiologies: Rasmussen aneurysms, septic emboli, necrotizing PNA, traumatic pseudoaneurysm
Systemic collateral arterial source: hypertrophied extrapleural vessels
Relative:
Uncorrectable bleeding diathesis
Contrast allergy (premedicate, as time allows)
Renal impairment
CTA (systemic arterial rather than PA timing): Not required in an emergent situation if the hx is convincing, but it’s becoming more the standard of care to improve planning, reduce failure rate, reduce surgical interventions.
Hypertrophied bronchial artery is a clear indication for angio in the setting of massive hemoptysis
Evaluate for nonstandard anatomy, ectopic origins of bronchials
Bronchoscopy
Useful in identifying bleeding side & confirming hemoptysis is not secondary to epistaxis, which it can be in some cases
Locoregional therapy becoming more common: laser coag, temporary bronchial plug
Underlying etiology? Is bronchial bleed or PA bleed more common?
Massive hemoptysis? Or can the pt be managed conservatively?
Consent: Risk of non-target embolization (including paralysis from embolizing spinal artery or stroke if bronchial to PV shunt unrecognized), hemoptysis recurrence (up to 27% in 1st month), chest pain, bronchial ischemia/necrosis (delayed), contrast nephropathy, access site complications